Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 21, 2021. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says that the Plan will not 
cover care from a provider who does not work with the health Plan unless one of the following situations 
applies: emergency or urgently needed services when the network is not available, out of area dialysis services, 
and cases in which Plan authorizes use of out-of-network providers. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on September 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Genetic Testing provided on September 15, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Genetic Testing. You say that you are asking for the claim to be reevaluated and 
reverse the initial adverse determination and allow full reimbursement of the claim. The Plan denied your 
request. The Plan says prior authorization is required for an out-of-network office 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 Genetic Testing provided on September 15, 2021 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom fabricated wheelchair back cushion, 
expandable controller, harness and stealth gel pads. 
 
You asked the Plan to pre-approve the cushion, expandable controller, harness and stealth gel pads.. You say 
that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan 
says you do not meet Medicare criteria for coverage of the requested accessories. 
 The Plan follows Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 
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 cushion, expandable controller, 
harness and stealth gel pads.. Our reviewer says that the requested expandable controller and harness exceed 
your needs and are not medically necessary. You do not require a ventilator, or non-proportional input devices. 
You do not require a separate display, other electronic devices or an attendant control. You have one power 
option on the wheelchair, but you do not need to control the power options through a joystick. Your right upper 
extremity function supports that you can control any power options through your own switches. Our physician 
reviewer found you do not have a diagnosis code listed in Group 2 or the Group 3  of the ICD-10 code list of 
the governing LCA, therefore; you do not meet criteria for a positioning back cushion. Because you do not 
meet criteria for a positioning back cushion, you also do not meet criteria for a custom fabricated back cushion. 
Additionally, gel pads are not medically necessary as they exceed your needs and do not serve a primary 
medical purpose. 
 
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 cushion, expandable controller, harness and stealth gel pads. have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the custom fabricated wheelchair back 
cushion, expandable controller, harness and stealth gel pads.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from April 12, 2021, to 
April 16, 2021, as billed with Diagnosis Related Group (DRG) 682. 
 
You asked the Plan to pay for inpatient care billed with DRG 682. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 682 is not supported as the diagnoses of acute kidney failure, unspecified (N17.9) and acidosis (E87.2) are not supported 
in the medical record. The Plan argues that DRG 195 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for inpatient care as billed with DRG 682. Our 
reviewer says that the billed DRG is not supported in the record. Our physician reviewer found that the 
documentation supported an admission for pneumonia. Even though acute kidney injury (AKI) was 
documented, supporting documentation was not found within the submitted medical record. The enrollee has a 
current medical history significant with chronic kidney disease (CKD) stage 3. Based on the best documented 
glomerular filtration rate (GFR) contained within the medical record, creatinine baseline would be 2.6. To 
support AKI in an enrollee with preexisting CKD, the medical record must support one of the following: an 
increase in serum creatinine - 1.5 times or more time baseline or an increase in serum creatinine to 4.0 mg/dL, 
or higher, with an increase of at least 0.5 mg/dL, or a decrease in GFR greater than 75%. Documentation stated, 
"patient has good urine output". In addition, acidosis is not supported clinically by the documentation received. 
The review has determined that the medical records do not support the billing of acute kidney failure, 
unspecified (N17.9) and acidosis (E87.2). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care as billed with DRG 682 have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient hospital care provided from April 12, 2021, to April 
16, 2021, as billed with Diagnosis Related Group (DRG) 682.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of 
the abdomen/pelvis provided on November 7, 2021, billed with code 74176. 
 
You asked the Plan to pay for the CT scan interpretation as billed. You say that this should be paid as the 
enrollee had multiple exams on the date of service. The Plan denied your request. The Plan says there is no 
evidence that the billing physician provided more than one CT scan interpretation. As such, the second claim 
was correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that exact duplicate claims are denied, but such 
denials may be appealed. 
 
In this case, the evidence supports that this claim is a duplicate since there is no evidence that more than one 
interpretation was performed. This was correctly denied. Therefore, we decided that the Plan does not have to 
pay for the interpretation of the computed tomography (CT) scan of the abdomen/pelvis provided on November 
7, 2021, billed with code 74176.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for the enrollee. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says although this item is requested, no allowed amount is listed on the quote submitted. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion device. 
 
You asked the Plan to pre-approve the requested device. You say that you have very limited range of motion 
due to swelling. The Plan denied your request. The Plan says you do not qualify per the guidelines. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
We looked at the file and the rules. You have not had total knee replacement surgery. The device was also 
requested more than 2 days after your procedure. Based on this information, we decided that the Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
passive motion device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy evaluation (97167) provided on 
April 27, 2021. 
 You asked the Plan to pay for occupational therapy services. You say that these services were medically 
necessary and were billed correctly. The Plan denied your request. The Plan says these services are not 
supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 97167 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by an 
Occupational Therapist. There is no indication that the Nurse Practitioner was present on site while the therapy 
services were being rendered. The incident-to requirements have not been met in this case. Based on this 
information, we decided that Medicare rules for coverage of occupational therapy services have not been met. 
Therefore, we decided that the Plan does not have to pay for the occupational therapy evaluation (97167) 
provided on April 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care to return to your prior level of 
function. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to 
an IRF. 
 
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) purchased on November 12, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that these hearing aids were necessary, and you should 
be reimbursed for some of the cost. You trust the provider you used, and feel they offered a better selection at a 
better price. The Plan denied your request. The Plan says your benefit does not cover hearing aids that are 
purchased from providers outside of the specified hearing vendor network group. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased through the Plans specified routine hearing vendor.  
 
We looked at the file and the Plan's rules. The hearing aids in this case were purchased from a provider who is 
not part of the specified vendor network. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5261) purchased on November 12, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the observation care provided on September 1, 2021. 
 
You asked the Plan to pay for the observation care. You say that clinical notes support medical necessity. The 
Plan denied your request. The Plan says that code 99222 has a conflict with code 99217. 
 
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. 
 
In this case, the CPT Code Manual definition of code 99217 is observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.]).  
 
We find that CPT code 99217 is supported by the records. It does look like there was intent to admit the 
enrollee to inpatient based on the note from one provider. However, the other note provided seems to show that 
the enrollee was under observation in the emergency department. We are unable to confirm that initial hospital 
care (code 99222) was billed and paid. We are unable to see some evidence that it was correct for the provider 
to bill and be paid for 99222, such as showing that this hospital stay was billed as inpatient. As it stands with 
the documentation we have, we cannot confirm anything, not even the Plans argument that 99222 was billed 
or paid. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for the 
observation care provided on September 1, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a medical eye exam and ophthalmic 
ultrasound provided on November 4, 2021. 
 
You asked the Plan to waive the copayments for a medical eye exam and ultrasound. You say that the sole 
purpose of the visit was for a glaucoma screening and should not be liable for the copayment. You also say that 
any other tests were the providers own doing. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing 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 $45 
copayment for basic imaging services, including ultrasound. The Plan contract also says that enrollees must pay 
a $40 copayment for medical eye exams to diagnose and treat diseases and conditions of the eyes. 
 
The medical record shows you had a medical eye exam on November 4, 2021. A medical eye exam is subject 
to a cost sharing amount. You have been asked to pay the allowed amount of $11.40, which is less than the $45 
copayment for an ultrasound. An ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. You have also been asked to pay a $40 copayment for a medical eye 
exam. A medical eye exam falls within the Vision Care benefit category. You have been asked to pay a total of 
$51.40 ($11.40 copayment + $40 copayment = $51.40). 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 a 
medical eye exam and ophthalmic ultrasound provided on November 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a fracture treatment procedure performed 
on December 16, 2021. We also decided that the Plan does not have to waive the coinsurance for surgical 
supplies provided on December 16, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for the fracture treatment and surgical supplies. 
You say that the anchor and screw were medically necessary. You say that you would like reconsideration of 
the charges. The Plan denied your request. The Plan says the correct copayment and coinsurance was applied. 
 
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 $50 copayment for services provided in an ambulatory surgical center. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for prosthetic devices, 
supplies, and orthotics. 
 
You have been asked to pay a $50 copayment for the fracture treatment. The fracture treatment falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. You have also been asked to pay $851.63 for the surgical supplies, which is 20% of 
the allowed amount ($4,258.13 allowed amount x 20% coinsurance = $851.63). The surgical supplies fall 
within the Prosthetic Devices and Related Supplies benefit category. The total for the procedure is $901.63. 
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 fracture treatment procedure performed on December 16, 
2021. We also decided that the Plan does not have to waive the coinsurance for surgical supplies provided on 
December 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services. The Plan denied 
your request. The Plan says criteria for admission to the IRF setting have not been met. The enrollee's ongoing 
skilled therapy and nursing needs can be provided at a lower level of care 
 
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 enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.