Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on May 24, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that these 
tests would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, we decided that the Plan has to pay for the laboratory services 
provided on May 24, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thyroid specialist to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a thyroid specialist. You say that this is the only provider that can get you 
off your medication. You've seen in-network providers and they did not help you and would not help you figure 
out your medications. The Plan denied your request. The Plan says there was no preauthorization by a primary 
care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was 
not an emergency. Therefore, the decision is upheld. 
 
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 network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a thyroid specialist to be provided 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 codes 77002 and S0020 billed for date of service 
January 25, 2022. 
 
You asked the Plan to pay for procedure codes 77002 and S0020. You say that you have provided 
documentation to support payment. The Plan denied your request. The Plan says payment for code 77002 is 
bundled into payment for code 27096. In addition, the Plan says that code S0020 is not payable. 
 
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 77002 
is a column II code to column I code 27096. This claim has not been billed with an appropriate modifier to 
bypass the edit. In addition, we find that procedure code S0020 has a Status Indicator of I on the Physician Fee 
Schedule. This means that procedure code S0020 is not valid for Medicare purposes. Therefore, we decided 
that the Plan does not have to pay for procedure codes 77002 and S0020 billed for date of service January 25, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wheelchair ramp provided on March 29, 2022. 
 
You asked the Plan to pay for a wheelchair ramp. You say that you sent in paperwork regarding your 
appointment of representative. You say that the member has been through the provider, and they were able to 
get the ramp installed. The Plan denied your request. The Plan says a wheelchair ramp is a non-covered item by 
Medicare. 
 
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. 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 pay for a wheelchair ramp provided on March 29, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 10, 2022, to June 
13, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that the services were 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 record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation 
care) would span two midnights. 
 
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 from June 10, 2022, to June 13, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided from March 2, 2022, to 
March 5, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that you were told it was going to be 
inpatient, and that we wouldn't have any additional bills. 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 $325 
copayment for outpatient hospital observation.  
 
You have been asked to pay a $325 copayment for an MRI. This item/service falls within the outpatient 
hospital observation 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 magnetic 
resonance imaging (MRI) provided from March 2, 2022, to March 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 8, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 procedure code 70450 billed for date of service April 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for a diagnostic mammogram 
and ultrasound provided on June 17, 2022. 
 
You asked the Plan to waive the deductible and coinsurance for the mammogram and ultrasound. You say that 
you feel the services should be covered. 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. Your 
contract with the Plan says that there is $200 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. Your contract with the Plan also clearly says that you must pay a 10% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies after the deductible is met. 
 
The item or service you asked the Plan to waive the deductible and coinsurance 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 $200 deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not been met at the time the mammogram and ultrasound 
were received on June 17, 2022. Once the deductible was met, the 10% coinsurance amount of $10.78 was 
applied to the ultrasound procedure. Therefore, we decided that the Plan does not have to waive the deductible 
and coinsurance for a diagnostic mammogram and ultrasound provided on June 17, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical nasal sinus endoscopy provided to the enrollee on May 18, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied codes remain not supported. 
 
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. Our doctor found that the case file does not contain an operative report. 
Consequently, there is no clinical documentation to substantiate the plan's denial. It appears that the plan used 
an operative report to deny the services, but did not provide this operative report for review. Therefore, we 
decided that the Plan has to pay for surgical nasal sinus endoscopy provided to the enrollee on May 18, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for date of service November 1, 
2021. 
 You asked the Plan to pay for procedure code 97110. You say that this service is supported in the record and 
should be paid. The Plan denied your request. The Plan says payment for code 97110 is bundled into payment 
for code 92526. 
 
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 97110 
is a column II code to column I code 92526. 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 97110 billed for date of service November 1, 
2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on March 22, 2022, to 
April 20, 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 claims were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that HHAs must send a Notice of Admission (NOA) to 
Medicare. 
 
We looked at the file and Medicare rules. The file shows that a valid NOA was not submitted for these 
services. 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 home health services rendered on 
March 22, 2022, to April 20, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services rendered on October 7, 
2021, to December 23, 2021. 
 
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 are not covered. 
 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 these 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 outpatient mental health services rendered on 
October 7, 2021, to December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete upper dentures (D5110), and complete lower 
dentures (D5120) provided on January 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to reimburse you for your 
out-of-pocket costs. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 26, 2022. The 
Plan correctly applied the benefit to this purchase of the dentures and paid the full dental benefit. Therefore, we 
decided that the Plan does not have to pay for complete upper dentures (D5110), and complete lower dentures 
(D5120) provided on January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 20, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 20, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay an additional amount for the inpatient services provided on March 14, 
2021, through April 27, 2021. 
 
You asked the Plan to pay an additional amount for the inpatient services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that the 
documentation submitted does not support the services billed. 
 
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 documentation submitted does not indicate what specific 
services have been denied and why. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case the Plan's denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pay an additional amount for the inpatient services provided on March 14, 2021, 
through April 27, 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: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve ten visits. We decided that the Plan does not have to pre-approve 
the other ten visits.  You asked the Plan to pre-approve twenty additional physical therapy (PT) visits.. You say that it is difficult to 
determine if all dates would be considered medically necessary due to the lack of objective progress shown in 
the minimal clinical documentation received for review. The Plan says that the enrollee could benefit from PT 
at home. 
 
We decided that the Plan has to pre-approve ten visits.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 for the visits Our reviewer says that ten of the twenty 
requested visits are reasonable and necessary. The additional requested therapy generally is accepted as specific 
and effective therapy for the patients condition. Ten visits of the requested therapy would be appropriate with 
re-evaluation upon the completion of this therapy to determine if additional therapy is needed. The patient 
would benefit from the unique skills of a professional therapist to safely and effectively provide treatment. The 
treatment of 10 therapy sessions would be best performed under the supervision of a therapist. The requested 
services are not part of a maintenance program. The patient would benefit from a qualified therapist to develop 
a home exercise program. Ten of the requested 20 visits are medically necessary per Medicare Benefit Policy 
Manual, Chapter 15, Section 220.2. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve ten visits.  
 
We also decided that the Plan does not have to pre-approve the other ten visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 for the visits. Our reviewer says that beyond the first 
ten visits, additional visits cannot be approved at this 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 the other ten visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the other ten visits. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for date of service February 28, 
2022. 
 
You asked the Plan to pay for procedure code 97110. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 97110 is bundled into payment for code 92526.  
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 97110 
is a column II code to column I code 92526. 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 97110 billed for date of service February 28, 
2022.