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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied. The requested service cannot be recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a diagnostic ophthalmic ultrasound 
(76513) rendered on October 11, 2021. 
 
You asked the Plan to waive the coinsurance for a diagnostic ophthalmic ultrasound. You say that it should be 
covered, and you do not see why this has to be different than any other year that you go. You also say the 
provider informed you that you had to pay a facility fee. The Plan denied your request. The Plan says you were 
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 20% 
coinsurance up to $75 per day for Medicare-covered diagnostic radiology services.  
 You have been asked to pay $25.29 in coinsurance, which is 20% of the allowed amount for a diagnostic 
ophthalmic ultrasound ($126.45 allowed amount x 20% coinsurance = $25.29). A diagnostic ophthalmic 
ultrasound falls 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 coinsurance for a diagnostic ophthalmic ultrasound (76513) rendered on 
October 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are wheelchair bound and require the 
proper amenities in order for you to care of yourself safely. At this time, you're unable to take a bath safely due 
to the complications as a result of one stroke. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal (D3330) and crown (D2750) for tooth # 31. 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says root canal is not listed as a covered service. The Plan says that crown is not listed 
as a covered service either. 
 
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, the requested root canal and crown are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
root canal (D3330) and crown (D2750) for tooth # 31.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that delay in transferring the enrollee to a 
LTACH will jeopardize their ability to fully recover and regain maximum independence. The Plan denied your 
request. The Plan says the enrollee can continue to receive care that the current acute care hospital until stable 
for discharge. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that LTACH care is not medically necessary. Our physician reviewer found the enrollee was admitted with 
shortness of breath from a subacute nursing facility in the setting of metastatic lung cancer and having 
undergone right lobectomy and two cycles of chemotherapy. The record indicates that the enrollee requires 
acute care services. The enrollee continues to receive acute care services and these have not been denied.  The 
medical record does not indicate that the enrollee requires services that he is not currently receiving but that 
would be available at the LTACH facility.  The elements of the coverage rules are not satisfied.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97163 billed for date of service October 14, 
2021. 
 
You asked the Plan to pay for procedure code 97163. You say that you have provided medical records to 
support payment for this code. The Plan denied your request. The Plan says procedure code 97163 is not 
supported in the medical records. 
 
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 97163 is Physical therapy evaluation: high complexity, 
requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities 
that impact the plan of care; an examination of body systems using standardized tests and measures addressing 
a total of 4 or more elements from any of the following: body structures and functions, activity limitations, 
and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and 
Clinical decision making of high complexity using standardized patient assessment instrument and/or 
measurable assessment of functional outcome.  Typically, 45 minutes are spent face-to-face with the patient 
and/or family. 
 
We asked our coder 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 procedure code 97163. Our reviewer says that procedure 
code 97163 is not supported in the medical records. Our reviewer found the medical documentation supports a 
home visit, so in this case there is a more appropriate Healthcare Common Procedure Coding System (HCPCS) 
code that would be reported.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 97163 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 97163 billed for date of service October 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on August 27, 
2021. 
 
You asked the Plan to pay for code 0012M. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are 
non-covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the CxBladder testing (0012M) provided on August 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for basic life support, emergency transport 
ambulance service (A0429) and ground mileage (A0425) rendered on August 20, 2021. 
 
You asked the Plan to waive the copayment for basic life support, emergency transport ambulance service and 
ground mileage. You say that you were in the hospital, and you cannot afford this bill. The Plan denied your 
request. The Plan says you were 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 $325 
copayment per trip for ambulance services.  
 
 
 You have been asked to pay a $325 copayment per trip for basic life support, emergency transport ambulance 
service and ground mileage. Basic life support, emergency transport ambulance service and ground mileage fall 
within the ambulance services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for basic life 
support, emergency transport ambulance service (A0429) and ground mileage (A0425) rendered on August 20, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, insulin 
and had stable vital signs. The enrollee was at a modified independent to stand by assist level for functional 
mobility including gait to 100 feet x 2 with a rolling walker. She does not require skilled nursing or therapy 
services on a daily basis. The enrollee does not require the necessary services on an inpatient basis, in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for external electrocardiographic recording (93226) provided on 
October 11, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for external electrocardiographic recording. You say that the service at issue was a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-
network care have not been met. 
 
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 external electrocardiographic recording (93226) 
provided on October 11, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician office visit (99213) provided on October 5, 2021, 
by an out-of-network provider. 
 
You asked the Plan to pay for a physician office visit. You say that the service at issue was a necessity for your 
care but you were not able to get a referral from your primary care physician due to a personality conflict. The 
Plan denied your request. The Plan says rules for payment for out-of-network care have not been met. 
 
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 a physician office visit (99213) provided on 
October 5, 2021, by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that the services are necessary. The Plan denied 
your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that massage is not covered as an isolated treatment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of massage therapy have not been met. Therefore, we decided that the Plan does not have to pre-
approve massage therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health services provided 
from September 9, 2021, to September 14, 2021. 
 
You asked the Plan to waive the copayment for the inpatient mental health services. You say that you were 
under the impression that inpatient copayment were only applied once a year. 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 $315 per 
day for days 1-5 and $0 per day after day 5 for each mental health admission.  
 
The records show that you were in the hospital from September 9, 2021, to September 14, 2021. Therefore, you have been asked to pay $315 per day for the first 5 days of inpatient mental health services. The total for your 
stay is $1,575 ($315 copayment x 5 days = $1,575). The inpatient mental health services fall within the 
Inpatient 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. Therefore, we decided that the Plan does not have to waive the copayment for inpatient 
mental health services provided from September 9, 2021, to September 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation services provided on September 9, 2021. 
 
You asked the Plan to pay for the transportation services. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the transportation services provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an urgent care visit provided on July 28, 
2021. 
 
You asked the Plan to reduce the copayment for an urgent care visit. You say that you would like the 
copayment reduced because you did not see the specialist. The Plan denied your request. The Plan says the 
proper copayment was applied for the service that was billed. 
 
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 each covered office visit to other providers for urgently needed services.  
 
  You have been asked to pay a $40 copayment for an urgent care visit. An urgent care visit falls within the 
Urgently needed services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for an urgent 
care visit provided on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 3, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 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, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479). 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81479).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 22, 2021. 
 
You asked the Plan to pay for the lab services. You did not provide an argument in your appeal request. The 
Plan denied your request. The Plan says you billed an incorrect place of service on the claim.  You billed with 
place of service 11, which indicates that the sample was taken from the patient in an office setting.  However, 
the records show that the specimen was taken from the patient in a psychiatric partial hospitalization facility, 
which is place of service 52.  The Plans says that they have tried to obtain corrected information from you 
multiple times.  
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with an office POS code. 
The records do not support that the sample was taken in an office setting. Therefore, we decided that the Plan 
does not have to pay for lab services provided on April 22, 2021.