Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on December 
11, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you do not want to pay the 
copayment for the service that was rendered. The Plan denied your request. The Plan says the proper 
copayment was applied for the service that was rendered. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for In-network per visit.  
 
  You have been asked to pay a $10 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently needed services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an urgent 
care visit provided on December 11, 2021.  
 
Your complaint about your experience with this provider is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on December 28, 2021, to 
December 30, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that an inpatient admission was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the orthopedic surgeon recommended no surgery because of multiple co-morbidities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided on December 28, 2021, to December 30, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder-arm orthosis (L3960) provided on March 8, 2022. 
 
You asked the Plan to pay for a shoulder-arm orthosis. You say that the item at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the patients medical record adequately supports the medical necessity for the item.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical records do not discuss the item at issue. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a shoulder-arm orthosis (L3960) provided on March 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain (70450) 
provided on January 10, 2022. 
 
You asked the Plan to pay for CT of the head or brain. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 70496 and 70450. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for computed tomography (CT) of the head or brain (70450) 
provided on January 10, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided 
November 23, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that your physician provided medically 
necessary services to the enrollee in good faith. In consideration for the services rendered, your doctor is 
seeking reimbursement. The Plan denied your request. The Plan says services not supported without required 
documentation. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy 
services (90832) provided November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a HFCWOD. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive 
pulmonary disease (COPD) and recurrent episodes of acute bronchitis. She has been prescribed a HFCWOD 
and this is apparently a renewal. The records do not include evidence of bronchiectasis. The clinical visit notes do not include bronchiectasis as a diagnosis and there are no reports of chest computed tomography scans. 
There is no diagnosis of cystic fibrosis or neuromuscular disease. There is no evidence of use of other airway 
clearance measures, such as the flutter valve. The criteria are not met and the services are not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of abdomen (74160) and 
thorax (71260). 
 
You asked the Plan to pre-approve CT scans. You say that the requested services were denied because of an 
abdominal aortic aneurysm (AAA). You say that the provided records indicate that the request is being ordered 
for hepatic cysts. You also say that the services are medically necessary. The Plan denied your request. The 
Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve CT scans. Our reviewer says that the 
requested CT scans are not medically necessary. Our physician reviewer found the provided documentation 
does not include any specific clinical rationale for the requested CT scans. Therefore, the reviewer found that 
the requested CT scans are not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scans have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) of abdomen (74160) and thorax (71260).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical knee arthroscopy with synovectomy for the 
enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not the standard of care for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident regarding diagnostic imaging corroborating inflamed 
synovium. The documentation does support continued stiffness and decreased motion in the left knee. This is 
status post left total knee arthroplasty, with failure of therapy and medications. However, the requested surgery 
would not appear to be an indicated treatment, based on overall clinical and imaging findings. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the requested surgical knee arthroscopy with synovectomy, in 
this case, is not medically reasonable or necessary.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a surgical knee arthroscopy with synovectomy for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a back injection performed on December 
10, 2021. 
 
You asked the Plan to reduce the copayment for the injection. You say that you feel the procedure is not 
surgical. You say that you never paid more than a $20 specialist copayment previously. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for each outpatient surgery or procedure.  
 
You have been asked to pay a $150 copayment for the injection. The injection is classified as a surgical 
procedure and falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities 
and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for a 
back injection performed on December 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have severe OSA, previously 
treated with cpap, restrictive lung disease, pleural effusions, pulmonary hypertension. Mild chronic CO2 
retention is documented on an ABG. There is no diagnosis of COPD, thoracic restrictive disease, or 
neuromuscular disease. The appropriate treatment is bipap during sleep. Medicare does not cover a home 
ventilator when used as bipap. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and mandibular 
partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests 
and teeth) (D5214). 
 
You asked the Plan to pre-approve a complete upper denture and partial lower denture. You say that your 
dentures are not fitting properly. The Plan denied your request. The Plan says you have exceeded the frequency 
limit for these services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a complete 
upper denture and partial lower denture once every 5 calendar years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a complete upper and 
partial lower denture were previously covered on May 4, 2022. Based on this information, we decided that the 
Plan's frequency limit for coverage of a complete upper denture and partial lower denture has been exceeded. 
Therefore, we decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping 
materials, rests and teeth) (D5214).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 7, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered on February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the allergy testing provided on May 17, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the allergy testing provided on May 17, 2021 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on February 11, 
2022 
 
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the patients medical record adequately supports the medical necessity for the item.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical records do not discuss the item at issue. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on February 11, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were told no referral or authorization was 
needed and you would like the claim processed for payment. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on February 2, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided from August 21, 2021, to September 3, 
2021. 
 
You asked the Plan to pay for inpatient care. You say that these services were medically necessary, and the 
diagnosis codes billed on this claim are valid. The Plan denied your request. The Plan says that a diagnosis 
code is invalid or missing or requires additional digits. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a clear argument as to why these services 
should be denied. The Plan only states that a diagnosis code is invalid/missing/requires additional digits. The 
only diagnosis code mentioned in the file is D50.8, which is a valid diagnosis code, and the original claim 
submitted to the Plan was not included in the file. Based on the information provided by the Plan, it is not clear 
why these services are denied. Therefore, we decided that the Plan has to pay for inpatient hospital care 
provided from August 21, 2021, to September 3, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you are unable to care for yourself and you will 
need therapy. The Plan denied your request. The Plan says the records show your condition does not meet the 
requirements for coverage of skilled nursing facility services per chapter 8 of the Medicare Benefit Policy 
Manual. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
this does not meet criteria. Our physician reviewer found you do not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.