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

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the rehabilitation center provides dialysis services 
that you need. The Plan denied your request. The Plan says the medical records do not support the need for an 
intensive rehabilitation therapy program consisting of at least 3 hours of therapy per day at least 5 days per 
week. Criteria for admission to the acute inpatient rehabilitation setting have not been met. The enrollee's 
ongoing skilled therapy and nursing needs can be provided at a lower level of care such as at a skilled nursing 
facility, on an intermittent basis at home with home health care, or in a long-term care setting. 
 
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 that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least 3 hours a day 
and 5 days a week, or 15 hours over 7 consecutive days. Currently, the enrollee requires minimal assistance 
with ambulation when using a walker. The enrollee requires supervision for transfers and is modified 
independent with bed mobility. The enrollee has had a functional decline from their baseline level of function 
and would likely benefit from therapy, but they do not require the intensity of therapies provided on acute 
inpatient rehabilitation. 
 
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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for emergency ambulance transportation 
provided on April 2, 2022. 
 
You asked the Plan to reduce the copayment for emergency ambulance transportation. You say that you should 
only be responsible to pay a $120 copayment. The Plan denied your request. The Plan says that the copayment 
was applied 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 $240 
copayment for in-network emergency ground ambulance per date of service regardless of the number of trips.  
 
You have been asked to pay $240 for emergency ambulance transportation. Emergency ambulance 
transportation falls within the Ambulance 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 reduce the 
copayment for emergency ambulance transportation provided on April 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 11, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says documentation does not support payment 
for code 83789. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately. 
 
The services at issue in this case are for the purpose of specimen validity testing. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for anesthesia services 
provided on January 21, 2022. 
 
You asked the Plan to waive the deductible and coinsurance for the anesthesia. You say that feel you were 
billed twice. The Plan denied your request. The Plan says the correct deductible and coinsurance were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $250 deductible which applies to certain items and services. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for surgery services after the 
deductible is met. 
 
The anesthesia falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $250 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the anesthesia was received on January 21, 
2022. Once the deductible was met, the 20% coinsurance of the remaining amount was applied. Therefore, we decided that the Plan does not have to waive the deductible and coinsurance for anesthesia services provided on 
January 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on 
November 18, 2021 to December 22, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you feel you were misled 
because the Plan advertises free transportation but did not make that eligibility criteria clear. You say your 
copayments should be waived because you were admitted into the hospital on all dates of service. The Plan 
denied your request. The Plan says you have been charged the correct copayment 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 $300 
copayment per one-way trip by ground or air ambulance.  
 
You have been asked to pay a total of $1,500.00 ($300.00 x 5 trips = $1,500.00). The ambulance transport falls 
within the Ambulance 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 ambulance transport provided on November 18, 
2021 to December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 May 10, 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 procedure code 95117 billed for date of service March 1, 
2022. 
 
You asked the Plan to pay for procedure code 95117. You say that the enrollee's allergies require the shots to 
be given. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 95117 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 95117 billed for date of 
service March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismR Molecular Signature test (81479) provided on 
March 24, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these tests are payable by Medicare and that 
there denied as experimental in error. The Plan denied your request. The Plan says documentation does not 
indicate any anticipated change in the enrollees medication.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file and Medicare rules. The documentation does not show that the testing at issue was 
ordered by the enrollees treating physician for a specific medical problem or treatment strategy. The records 
do not show any anticipated change in the enrollees medication. Based on this information, we decided that 
Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for the PrismR Molecular Signature test (81479) provided on March 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service May 11, 
2022. 
  You asked the Plan to pay for procedure code 70480. You say that the enrollee had multiple exams on this date 
of service and the reports support the level of service. You say that the claim should be reconsidered for 
processing. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment for 
code 70450. 
 
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 70480 
is a column II code to column I code 70450. 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 70480 billed for date of service May 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service March 17, 
2022. 
 
You asked the Plan to pay for procedure code 99291. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service March 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage of this device have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not require frequent self-
adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the full medical and functional 
criteria for a IRF admission. The Plan denied your request. The Plan says the records do not show that the 
enrollee needs to take part in 3 hours of therapy a day at least 5 days a week or 15 hours per week or they need 
an intensive team for their care, nor does the enrollee need to be seen by a rehabilitation doctor at least 3 times 
a week for evaluation of functional and medical goals and progress. The services the enrollee needs can be 
provided safely in other settings like a skilled nursing facility, home with home health services or home with 
outpatient therapy. 
 
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 that the complexity of the enrollee's nursing medical and rehabilitation may require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was 
hospitalized on September 18, 2022, for pyelonephritis and urosepsis as well as acute kidney injury, vomiting 
and diarrhea. A clinical progress notes dated September 21, 2022, indicated that the enrollee was more 
confused and blood cultures were positive. The rehabilitation pre-admission assessment was performed on 
September 20, 2022, and it is unclear what the medical status of the enrollee is in terms their infection and 
mental status. The enrollee may require the oversight of a rehabilitation physician, but it is unclear if they 
would benefit from and participate in therapies and is medically stable to do so at this point in time. 
 
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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for radiologic examinations of both hands 
provided on February 4, 2022. 
 
You asked the Plan to waive the cost sharing for x-rays. You say that the cost share is too expensive and would 
like the claims to be reviewed. The Plan denied your request. The Plan says the deductible applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible which applies to in-network Medicare-covered 
standard X-ray service.  
 
The item or service you asked the Plan to waive the cost sharing for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,000 deductible which applies to in-network Medicare-covered 
standard X-ray service. This cost sharing is a contractual obligation that had not been met at the time x-rays 
were received on February 4, 2022. At the time this claim was processed, $369.42 of the $1,000 deductible had 
been met. The full allowed amount of this claim applied to the deductible, resulting in a deductible 
responsibility of $82.88. Therefore, we decided that the Plan does not have to waive the cost sharing for 
radiologic examinations of both hands provided on February 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93000 billed for date of service July 26, 
2021. 
 
You asked the Plan to pay for procedure code 93000. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 93000 is bundled into payment for code 93015. 
 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 93000 
is a column II code to column I code 93015. 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 93000 billed for date of service July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S0164 billed for date of service September 
25, 2021. 
 
You asked the Plan to pay for procedure code S0164. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S0164 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S0164 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S0164 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S0164 billed for date of service September 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you need this power wheelchair when you 
leave the house. The Plan denied your request. The Plan says the criteria for coverage have not been satisfied. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Specifically, you are indicating that the power 
wheelchair will only be used outside of the home. Although this item may be helpful, neither Medicare nor the 
Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-
approve a power wheelchair.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care services provided in the 
Republic of India from January 17, 2022, to February 21, 2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that you are requesting payment for 
these services. The Plan denied your request. The Plan says the copayment amount you are being charged is 
correct; therefore, the reimbursement amount you have been issued is correct. 
 
Medicare rules say that items and services furnished outside of the United States and its territories are excluded 
from coverage except in limited, specified circumstances. 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 $90 copayment for worldwide emergency care services. 
Based on the federally recognized exchange rates for each date of service in question, the 8,800 would 
exchange to $117.86. However, the Plan has given you a more favorable exchange rate and approved a total 
amount of $118.37. After the $90 copayment is applied to the claim, the amount reimbursed to you is $28.37. 
 
You have been asked to pay $90 copayment for worldwide emergency care. Worldwide emergency care falls 
within the Emergency Care 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 emergency 
care services provided in the Republic of India from January 17, 2022, to February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain injections to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the injections. You say that you have been a patient here for over 3 years. 
The Plan denied your request. The Plan says there are in-network providers available to provide the requested 
services in this case. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has confirmed there are 
network providers available who can provide the injections at issue in this appeal. We found no exception that would require the Plan to pre-approve these injections. Therefore, we decided that the Plan does not have to 
pre-approve pain injections to be provided by an out-of-network (OON) provider.  
 
No continuity of care issue has been identified in this case.