Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chest computed tomography (CT) scan (71250). 
 
You asked the Plan to pre-approve a chest CT scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not necessary because a similar study has been approved. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a chest CT scan. Our reviewer says that 
the requested CT scan is not medically necessary. Our physician reviewer found the medical records, including 
the most recent clinical encounter, do not mention a chest CT or include any discussion about lung cancer 
screening. 
 
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 chest CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a chest computed tomography (CT) scan (71250).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a procedure provided on March 28, 2022. 
 
You asked the Plan to waive the copayment for a procedure. You say that you should not have to pay this 
copayment. The Plan denied your request. The Plan says the copayment applied was 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 a $390 
copayment for outpatient surgery.  
 
You have been asked to pay a $390 copayment for a procedure. A procedure falls within the Outpatient 
Surgery Including Services Provided at Hospital Outpatient Facilities And Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a procedure provided on March 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DME supplies provided on July 29, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for DME supplies. You say that you thought the items would be covered by 
insurance. The Plan denied your request. The Plan says the service can be provided by an in-network 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 DME supplies provided on July 29, 2021, by an 
out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the ER visit provided on January 9, 2022. 
 
You asked the Plan to pay more for the ER visit. You say that the medical records should be reviewed, and the 
claim reconsidered for payment. The Plan denied your request. The Plan says the documentation does not 
support the presenting problem had a significant threat to life or physiological function. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
  In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 more for the ER visit. Our reviewer says that the 
documentation does not support the originally billed CPT code 99285. Our reviewer found that there was no 
medical decision making of high complexity. 
 
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 ER visit have not been met. Therefore, we decided that the Plan does not 
have to pay more for the ER visit provided on January 9, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery services provided on June 10, 2021. 
 
You asked the Plan to pay for the surgery services. The Plan denied your request. The Plan says original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for surgery services provided on June 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular ablation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that endovascular ablation is covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have significant peripheral artery 
disease and had vascular surgery. The Medicare rules require the absence of peripheral artery disease for 
coverage of endovenous ablation. The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovascular ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $290 copayment for outpatient surgery performed on 
February 15, 2022. 
 
You asked the Plan to waive the $290 copayment for outpatient surgery. You say that you should not be 
responsible for this cost share. The Plan denied your request. The Plan says this claim was processed 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 $290 
copayment for outpatient surgery.  
 
 
 
 
 
 
 You have been asked to pay $290 for outpatient surgery. Outpatient surgery 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 $290 copayment for outpatient surgery 
performed on February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 15, 
2021. 
 
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 claim lines with the GZ modifier are automatically denied as non-covered services. 
 
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 0089U and 81345 is not supported in the medical record. Specifically, these codes were 
billed with a GZ modifier, which triggers an automatic denial. These codes are not covered. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 15, 
2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from April 4, 2022, to April 12, 
2022. 
 
You asked the Plan to pay for the services provided. You say that you were reassured you could use any 
dentist. The Plan denied your request. The Plan says the claim was paid correctly. 
 
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.  
 
We looked at the file, and Medicare rules. The file shows that you received an oral exam, x-rays, crown, and 
core buildup from an out-of-network provider. You were charged the difference between the billed amount and 
the allowed amount.  If you choose to see an out-of-network dentist, you might be billed by that provider for any amount greater than 
what the plan pays. Therefore, we decided that the Plan does not have to further pay for the dental services 
provided from April 4, 2022, to April 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for compression stocking on December 09, 
2021. 
 
You asked the Plan to waive the coinsurance for compression stocking. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 
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 a 20% 
coinsurance for durable medical equipment (DME) provider. Covered items include, but are not limited to 
wheelchairs, crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a provider for use 
in the home, IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, and walkers. The 
provider billed in the amount of $276.20. $276.20 x 20% = $55.24. Therefore, results in the total cost sharing 
amount of $55.24.  
 
 
 You have been asked to pay a 20% coinsurance for compression stocking. Compression stockings fall within 
the Durable medical equipment (DME) and related 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 coinsurance for compression stocking on December 09, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 pressure reducing support surface (low air 
loss mattress). 
 
You asked the Plan to pre-approve low air loss mattress. You say that your mattress is worn out and you get 
bed sores all the time. The Plan denied your request. The Plan says you do not meet the Medicare criteria for 
the requested mattress.  
The Plan follows Medicare rules. Medicare rules state that group 2 pressure reducing support surfaces such as a 
low air loss mattress are only covered under certain conditions. 
 
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 low air loss mattress. Our reviewer says 
that you do not meet the Medicare criteria for the requested group 2 pressure reducing support surface. Our 
physician reviewer found the records do not show that you have multiple stage 2 pressure ulcers located on the 
trunk or pelvis which have failed to improve over the past month, that you have large or multiple stage 3 or 4 
pressure ulcers on the trunk or pelvis, or that you have had a myocutaneous flap or skin graft for a pressure 
ulcer on the trunk or pelvis within the past 60 days. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of low air loss mattress have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 2 pressure reducing support surface (low air loss mattress).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve polysomnography (PSG) (95811). 
 
You asked the Plan to pre-approve polysomnography. You say that this testing is medically necessary as the 
enrollee has severe sleep apnea and has failed auto CPAP in the past. The Plan denied your request. The Plan 
says the criteria for polysomnography have not been met. The enrollee had a previous sleep study with titration 
last year with a different provider. However, no results or follow-up is noted. 
 
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 polysomnography. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this case, the enrollee is said to have previously undergone diagnostic sleep 
testing and a titration study in the previous year. The information provided for review was limited regarding the 
enrollees obstructive sleep apnea. There were no details about the prior sleep testing, nor was it otherwise 
indicated why repeat sleep testing has been ordered. With this in mind, it cannot be said that testing has been 
ordered for an indication supported within the Local Coverage Determination. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of polysomnography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve polysomnography (PSG) (95811).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (20552, 20610, 97012, 97014, 97112, 
97140) provided February 18, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the primary insurer is liable for payment. 
 
 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an 
explanation of benefits from the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the physician services until the primary insurer has denied the claim for these services. Additionally, code 
97014 has a status of "I" and is ineligible for Medicare payment. Therefore, we decided that the Plan does not 
have to pay for physician services (20552, 20610, 97012, 97014, 97112, 97140) provided February 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulatory surgical boot (L3260) provided from April 19, 
2022, to May 9, 2022. 
 
You asked the Plan to pay for an ambulatory surgical boot. You say that the item at issue was a medical 
necessity for you. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for an ambulatory surgical boot (L3260) 
provided from April 19, 2022, to May 9, 2022.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the lower level of care in skilled nursing cannot 
provide the total interdisciplinary team approach needed to keep this patient healthy and safe. The Plan denied 
your request. The Plan says that the services you need can be provided safely in other settings. 
 
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. The 
enrollee is medically stable and does not need physical medicine and rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations 
of chronic medical conditions. There are no acute nursing needs identified or documented. At the current 
functional level, the enrollee does not need therapy 3 hours a day, 5 days a week. While the enrollee would 
benefit from physical and occupational therapy, the enrollee's rehab needs can be safely provided in an 
alternate and low intensity setting. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF care. 
 
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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient services provided to the enrollee on March 31, 2021. 
 
You asked the Plan to pay for the services. You say that you have called and provided the requested 
information multiple times, and still the claim is not paid. The Plan denied your request. The Plan says that the 
revenue code is not correct. 
 
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 has not substantiated their denial. The plan says that cataract removal 
needs to be billed with revenue code 270, which is for medical surgical supplies. This is not correct. The 
provider is reasonable in thinking that revenue code 360 is appropriate for this case. The plan is not correctly 
denying this claim. Therefore, we decided that the Plan has to pay for inpatient services provided to the 
enrollee on March 31, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care (99291) provided on February 18, 2022. 
 
You asked the Plan to pay for critical care. You say that you want the Plan to pay for these services. The Plan 
denied your request. The Plan says the billed services were not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that critical care is a time-based service and the total 
time that services are provided must be documented. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of critical care have not been met. Specifically, the records do not show documented time spent for 
this date of service. Therefore, we decided that the Plan does not have to pay for critical care (99291) provided 
on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation therapy from January 4, 2022, to 
March 3, 2022.  
 
You asked the Plan to waive the coinsurance for radiation therapy. You say that you were told you would not 
receive a bill for these services. 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 20% 
coinsurance for radiation therapy.  
 
 
 
 
 You have been asked to pay $5034.58 for radiation therapy. Radiation therapy 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 coinsurance for radiation therapy 
from January 4, 2022, to March 3, 2022.