Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
November 30, 2021, to December 6, 2021. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says there was a partial DRG adjustment 
recoupment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
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 the inpatient hospital services at the DRG 
originally billed. Our reviewer says that the services at issue in this case were not supported by the medical 
records. Our physician reviewer found that the provided records do not support the use of diagnosis of sepsis, 
severe sepsis, or acute kidney failure with tubular necrosis, although acute kidney injury (without tubular 
necrosis) would have been a more reasonable diagnosis for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from November 30, 2021, to December 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has a past medical history of Parkinson's disease and is living at home 
with weakness and frequent falls. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 
24, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you feel you should not 
pay a copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $40 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist. 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 a specialist office visit provided on June 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency transportation service and ground mileage 
provided on July 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for non-emergency transportation service and ground mileage. You say that you are 
requesting a retro pre-authorization for this transport. The Plan denied your request. The Plan says 
authorization to cover the services is required and not on file for this non-participating provider. 
 
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 non-emergency transportation service and ground 
mileage provided on July 2, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ground transportation provided on June 29, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for non-emergency ground transportation. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says the services were provided out-of-network and 
were not approved in advanced. 
  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 non-emergency ground transportation provided on 
June 29, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on May 3, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that the patient could not choose an in-network 
internal medicine since no other provider was allowed into the office during the COVID-19 pandemic. The 
Plan denied your request. The Plan says this provider is out-of-network with the Plan. The Plan also says that 
authorization was not obtained prior to the services being rendered. 
 
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 a specialist office visit provided on May 3, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service January 5, 
2022. 
 
You asked the Plan to pay for procedure code 87634. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 87634 is bundled into payment for code 87631.  
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 87634 
is a column II code to column I code 87631. 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 procedure code 87634 billed for date of service January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye exam and the refraction provided on July 14, 
2022. 
 
You asked the Plan to pay for the medical eye exam and the eye refraction. You say that the refraction was 
medically necessary because your vision is declining. The Plan denied your request. The Plan says the claim 
was paid correctly. 
 
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 a $35 
copayment for exams to diagnose and treat diseases and conditions of the eye. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed as a routine vision exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed with a routine eye 
exam. The record shows diagnoses of cataracts and glaucoma which makes the eye exam medical in nature. 
You have been asked to pay a $35 copayment for the medical eye exam. This medical eye exam falls within the 
vision care  Medicare-covered benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. Based on this information, we decided that the Plan's rules for 
coverage of the medical eye exam and the eye refraction have not been met. Therefore, we decided that the 
Plan does not have to pay for the medical eye exam and the refraction provided on July 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 23, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you are not sure why this is a 
separate bill from the hospital bill. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $325 copayment for ambulance services.  
 
The enrollee has been asked to pay a $325 copayment for ambulance services. This item/service falls within the 
ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance services provided on June 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry rendered on May 23, 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 procedure codes 83789 is not supported. 
 
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, the CPT Code Manual definition of code 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, there is no documentation of 
testing of non-drug analyte(s). 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 mass spectrometry 
rendered on May 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance service and ground mileage 
provided on June 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for non-emergent ambulance service and ground mileage. You say that you are 
requesting retro prior-authorization for this transport. The Plan denied your request. The Plan says the health 
plan requires prior authorization per the EOC. 
 
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 non-emergent ambulance service and ground 
mileage provided on June 25, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93042 billed for date of service January 14, 2022. 
 
You asked the Plan to pay for code 93042. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says code 93042 is not separately payable from code 99291. 
 
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 93042 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for code 93042 billed for date of service January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new prosthetic leg including a new foot and ankle 
system (L5301, L5620, L5629, L5637, L5645, L5647, L5679, L5683, L5685, L5910, L5940, L5968, L5981, 
L8400, L8420, L8440, L8470). 
 
You asked the Plan to pre-approve a prosthetic leg, new foot, and ankle system. You say that the requested 
prosthetics are necessary. The Plan denied your request. The Plan says records do not support functional status 
has advanced to K3, as your physician does not corroborate prosthetist's (vendor's) claim that you are a K3 
ambulator. 
 
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 a prosthetic leg, new foot and ankle 
system. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the record from the physician's office state you are a k2 
ambulator. The requested devices are only authorized for a K3 ambulator. You do not meet criteria for the 
requested items. 
 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 prosthetic leg, new foot and ankle system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a new prosthetic leg including a new foot and ankle system 
(L5301, L5620, L5629, L5637, L5645, L5647, L5679, L5683, L5685, L5910, L5940, L5968, L5981, L8400, 
L8420, L8440, L8470).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy (45380) 
provided June 28, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic procedure. You say that you are appealing the 
denied claim for colonoscopy with biopsy single/multiple which was prescribed by and performed by the 
doctor. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $250 
copay for each Medicare covered ambulatory surgical center visit.  
 
You have been asked to pay $250 copay for the diagnostic procedure. This item/service falls within the 
Outpatient hospital 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 the 
diagnostic colonoscopy (45380) provided June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the antibody; severe acute respiratory syndrome coronavirus 
2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) (86769) provided June 9, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you were required to present a negative 
COVID test in order to board your flight from Vancouver, Canada to your home in Kansas City, Missouri. The 
Plan denied your request. The Plan says COVID-19 testing for non-diagnostic testing for screening purposes is 
not covered by Medicare. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory service, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Medicare plans are not required to provide coverage of 
COVID-19 surveillance testing/screening (including an at-home over the counter COVID-19 test), which is 
testing used for public health or social purposes such as employment (return to workplace), education, travel, or 
entertainment. You can find this rule in https://www.cms.gov/files/document/covid-medicare-payment-covid-
19-viral-testing-flow-chart.pdf. Therefore, we decided that the Plan does not have to pay for the antibody; 
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) (86769) 
provided June 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for x-ray and physical performance test 
provided on July 21, 2022. 
 
You asked the Plan to waive the cost share for x-ray and physical performance test. You say that you should 
not be responsible for these charges; you did not pay for previous x-rays. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
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 for all 
other services, your coinsurance is 10% of the approved amount. The annual deductible applies. The 
coinsurance and deductible apply to the annual out-of-pocket maximum of $1700 for Diagnostic tests.  
 
  You have been asked to pay $262.16 for x-ray and physical performance test. A total of $235.95 was applied 
towards the deductible and $26.21 towards coinsurance. This x-ray and physical performance test falls within 
the Diagnostic tests 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 cost share for x-ray and physical 
performance test provided on July 21, 2022.
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 November 
5, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you feel you should not pay a 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $30 
copayment for urgently needed services.  
 
You have been asked to pay a $30 copayment for an urgent care visit. This item/service 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 November 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry coded 
83789 provided on July 20, 2022. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, the testing described by the 
billed code is considered specimen validity testing, which is not separately payable. Based on this information, 
we decided that Medicare rules for coverage of the mass spectrometry and tandem mass spectrometry have not 
been met. Therefore, we decided that the Plan does not have to pay for the mass spectrometry and tandem mass 
spectrometry coded 83789 provided on July 20, 2022.