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

 
We decided that the Plan does not have to pay for the inpatient consultation provided on March 1, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient consultation. You say that the treating provider depends upon the 
hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company. 
You also say that medically necessary services were provided to the enrollee in good faith. The Plan denied 
your request. The Plan says services from non-participating providers are not covered unless pre-authorized. 
 
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 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 inpatient consultation provided on March 1, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a crown on tooth #2 (D2740) provided on November 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are sending the x-ray again as proof of the 
date of service. The Plan denied your request. The Plan says that this service is denied. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the covered requested item or service was 
previously exhausted. Therefore, we decided that the Plan has to pay for a crown on tooth #2 (D2740) provided 
on November 9, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that this lab was medically necessary. The Plan denied 
your request. The Plan says these services were provided OON 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 lab services provided on May 10, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimburse you for the transplant related lodging, meals and transportation, per 
diem, (S9975) from March 18, 2022, to April 8, 2022. 
 
You asked the Plan to reimburse you for the transplant related lodging, meals and transportation. You say that 
your transplant coordinator advised you would be reimbursed for mileage and accommodations for any 
appointments with your transplant provider. The Plan denied your request. The Plan says that the claim 
processed correctly. 
 
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 documents do not specify what is considered a transplant 
related service or when the start of care would be. Therefore, we decided that the Plan has to reimburse you for 
the transplant related lodging, meals and transportation, per diem, (S9975) from March 18, 2022, to April 8, 
2022.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for you to receive IRF care. 
The Plan denied your request. The Plan says that the records do not show that the enrollee is able to do therapy 
that lasts at least 3 hours per day for at least 5 days a week. The enrollee is not expected to get a lot better in a 
short amount of time. The enrollee can receive the care they need at a skilled nursing facility. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the clinical documentation shows that the enrollee would be expected to require close medical 
supervision by a rehabilitation physician on an inpatient basis. Evaluating therapists state that the enrollee 
would tolerate and benefit from intense therapy thus the IRF criteria has been met and is medically necessary. 
Encephalopathy is an IRF compliant diagnosis. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 11, 2022, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. You say that you are an independent laboratory and there are 
no authorizations required for lab. The Plan denied your request. The Plan says the out-of-network services 
were not authorized. 
 
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 laboratory services provided on April 11, 2022, by 
an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on May 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that you work with a group of doctors who are 
participating providers and use your laboratory exclusively. You say the enrollee does not go to the laboratory, 
so they are not using out-of-network benefits.  The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
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 did not pre-approve the 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. The 
records provided for review do not show that the laboratory work was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the laboratory work provided on May 26, 2022, by an out-of-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine items and services and patch PTFE felt 6 by 6 
provided from June 19, 2021, to June 28, 2021. 
 
You asked the Plan to pay for the routine items and services and patch PTFE felt 6 by 6. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says these items are not separately 
reimbursable. 
 
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 the routine items and services and patch PTFE felt 6 by 6 are not supported in the medical record. 
Specifically, the routine items and services are included to the room and board, or the procedure rendered and 
are not separately reimbursed. The medical records received do not include documentation of the patch PTFE 
felt 6 by 6 billed. Based on this information, we decided that Medicare rules for coverage of the routine items and services and patch PTFE felt 6 by 6 have not been met. Therefore, we decided that the Plan does not have 
to pay for the routine items and services and patch PTFE felt 6 by 6 provided from June 19, 2021, to June 28, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64625). 
 
You asked the Plan to pre-approve the RFA. You say that the blocks were previously approved. You say that 
the blocks would not have been done if you knew the ablation would not be approved. The Plan denied your 
request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation used for sacroiliac joint pain 
is considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed 
radiofrequency. 
 
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 RFA. Our reviewer says that the 
requested radiofrequency ablation (RFA) is not medically necessary. Our physician reviewer found RFA of the 
lateral sacral branches is considered experimental/ investigational because of the wide variation in efficacy 
reported in the literature. Therefore, the requested RFA is considered 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA) (64625).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99221 provided on 
July 19, 2021. 
 
You asked the Plan to pay for the initial hospital care services as billed. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says the 
documentation does not support the services 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. 
 
In this case, the CPT Code Manual definition of code 99221 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A 
detailed or comprehensive examination; and Medical decision making that is straightforward or of low 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission are of low severity. Typically, 30 minutes are spent 
at the bedside and on the patient's hospital floor or unit. 
 
We asked our physical 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 initial hospital care services as billed. 
Our reviewer says that the documentation does not support the billed evaluation and management code. Our 
reviewer found the medical records appear to be incomplete in this case. Specifically, required documentation 
is missing that would support that the correct code was billed for the services rendered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the initial hospital care services as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the initial hospital care services coded 99221 provided on July 
19, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scans provided on April 19, 2022. 
 
You asked the Plan to waive the copayment for CT scans. You say that you were never told you would be 
responsible for a copayment. The Plan denied your request. The Plan says the cost share has been 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 $150 
copayment for in-network diagnostic procedures and tests. The Plan contract also says if multiple tests of the 
same type are performed in the same day one copayment will apply.  
 
You have been asked to pay $150 for CT scans. CT scans fall within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies 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 
CT scans provided on April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmology services provided on May 
12, 2022. 
 
You asked the Plan to waive the copayment for ophthalmology services. You say that the copayment has been 
incorrectly applied. The Plan denied your request. The Plan says the cost share has been 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 $45 
copayment for in-network Medicare-covered vision services.  
 
You have been asked to pay $45 for ophthalmology services. Ophthalmology services fall within the Vision 
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 ophthalmology services provided 
on May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for doctors office visits provided on February 
10, 2022, to May 11, 2022. 
 
You asked the Plan to waive the copayments for doctors office visits. You say that this is different than last 
year, and you shouldn't have to pay more. The Plan denied your request. The Plan says the copayments applied 
are correct. 
 
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 $15 
copayment for each primary care physician service.  
 
 
 
 
 You have been asked to pay $45 ($15 x 3 visits) copayment for doctors office visits. Doctors office visits fall 
within the Physician/ Practitioner Services, Including Doctors Office Visits 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 copayments for doctors office visits provided on February 10, 2022, to May 11, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist office visits provided on May 2, 2022, to May 13, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for specialist office visits. 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 specialist office visits provided on May 2, 2022, to 
May 13, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) and progressive lens (V2781) provided 
on April 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the glasses. The Plan denied your request. The Plan says these glasses were 
purchased from an OON provider. The Plan also says prior authorization was not obtained, and you were not 
referred by your primary care physician. 
 
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 authorization has been obtained for OON services. 
 
We looked at the file and the Plan's rules. The record shows you received these glasses from an OON provider 
without authorization. Based on this information, we decided that the Plan's rules for coverage of the glasses 
have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020) and 
progressive lens (V2781) provided on April 18, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the psychotherapy telehealth visit provided 
on June 02, 2022. 
 
You asked the Plan to waive the copayment for the psychotherapy telehealth visit. You say that telehealth 
therapy visits are supposed to be covered in full. 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 outpatient mental health care. 
 
You have been asked to pay a $40 copayment for the psychotherapy telehealth visit. This item/service falls 
within the outpatient mental health 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. The file shows that the Plans COVID-19 cost share waivers ended on May 
31, 2022. Therefore, we decided that the Plan does not have to waive the copayment for the psychotherapy 
telehealth visit provided on June 02, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99219 billed for date of service May 4, 2022. 
 
You asked the Plan to pay for procedure code 99219. You say that you would like this claim reprocessed based 
on the medical records. 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 99219 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 99219 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99219 billed for date of service May 4, 2022.