Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-care management training provided on January 11, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for self-care management training. You say that you were burned on 27% of your 
body. You were never told at any point that this would not be covered. The Plan denied your request. The Plan 
says prior authorization was not obtained for the services that were rendered. 
 
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 self-care management training provided on 
January 11, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home sleep test (hst) with type III portable monitor, 
unattended (G0399) provided on April 27, 2021. 
 
You asked the Plan to pay for the home sleep test. You say that the enrollee is reportedly snoring. You say that 
they are experiencing daytime sleepiness. You also say that the requested sleep study is medically necessary. 
The Plan denied your request. The Plan says the home sleep test is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that home sleep test is considered medically 
necessary for specific diagnosis codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home sleep test have not been met. Specifically, the home sleep test is not considered 
medically necessary for the diagnosis of primary insomnia. Therefore, we decided that the Plan does not have 
to pay for the home sleep test (hst) with type III portable monitor, unattended (G0399) 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and your needs can be met at a lower level of 
care such as in a skilled nursing facility, at home with home health services or at home with outpatient therapy. 
 
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 while the enrollee has a need for physical and/or occupational therapy, there 
is no documentation of a need for an intensive rehabilitation program such as 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 prophylaxis (D1110) provided by a participating provider on 
February 23, 2022. 
 
You asked the Plan to pay for prophylaxis. You say that the Plan should pay for this. The Plan denied your 
request. The Plan says services provided by an out-of-network provider are not covered. 
 
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. The Plan covers covered 
prophylaxis when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of prophylaxis have not been met. Therefore, we decided that the Plan does not have to pay for 
prophylaxis (D1110) provided by a participating provider on February 23, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for echocardiography services provided to the enrollee from July 23, 2021 
to July 27, 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 that evaluation and management codes are not covered for this specialty or provider type. 
 
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 provided a valid rationale as to why a Doctor of Medicine 
(MD) would not be appropriate for the services rendered. Therefore, we decided that the Plan has to pay for 
echocardiography services provided to the enrollee from July 23, 2021 to July 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99284) provided February 22, 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 documentation does not support the billed code. 
 
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 99284 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key component: detailed history; detailed exam; medical 
decision making of moderate complexity.  
 
We find that CPT code 99284 is not supported in the medical record. Specifically, the records support 99283 
with low presenting problem; low diagnostic procedures ordered; and moderate management options. Based on 
this information, we decided that Medicare rules for coverage of the physician services have not been met.  
 
 
 Therefore, we decided that the Plan does not have to pay for physician services (99284) provided February 22, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 1, 2021. You asked the Plan to pay for the services provided. You say that the services billed were the services 
performed. The Plan denied your request. The Plan says the standard of care is urinalysis with urine culture. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the 
documentation in the beneficiary's medical documentation. 
 
We looked at the file and Medicare rules. In this case, the medical records do not clearly document the 
physicians intent for the test to be performed. The medical records do not show that the testing is needed 
above the standard of care. 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 pay for the lab services provided on July 1, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Paxlovid tablet. 
 
You asked the Plan to pre-approve Paxlovid. You say that this drug is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the 
enrollee's medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Paxlovid tablet.  
 
Benefits for Paxlovid may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee arthroscopy (29881) provided on August 13, 2021. 
 
You asked the Plan to pay for the knee arthroscopy (29881). You say that you only handle the billing for the 
surgical assistant and the operative report should be reviewed for proper payment. The Plan denied your 
request. The Plan says Medicare cannot reimburse a surgical assistant's services if the assistant is an unlicensed 
practitioner and does not qualify to be a Medicare provider. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the knee arthroscopy (29881) 
provided on August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 13, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 January 13, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a spike bike purchased on January 8, 2021. 
 
You asked the Plan to reimburse you for a bike. You say that you thought you would be reimbursed $150 
towards the bike. You also say you were too scared to go to the gym during COVID-19. The Plan denied your 
request. The Plan says reimbursement for exercise equipment is not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The Plans rules for coverage of gym benefits/wellness allowance have not been met because reimbursement 
for exercise equipment is not a covered benefit. Therefore, we decided that the Plan does not have to reimburse 
you for a spike bike purchased on January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by an 
out-of-network provider on November 22, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you were having jaw pain. You 
say that you had to have a full evaluation. The Plan denied your request. The Plan says the benefit limit for 
D0150 has been met and 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. The Plan covers one 
comprehensive oral evaluation every three years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 was previously provided 
on August 25, 2020. Based on this information, we decided that the Plan's rules for coverage of a 
comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for 
a comprehensive oral evaluation (D0150) provided by an out-of-network provider on November 22, 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 were fully independent prior to your injury and 
you want to get back to that level of functioning. The Plan denied your request. The Plan says IRF care is not 
medically necessary and your needs can be met at a lower level of care such as in a skilled nursing facility or at 
home with home health services. 
 
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 while you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program such as 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the surgical preparation or creation of 
recipient site by excision of open wounds, and the adjacent tissue transfer, or rearrangement provided on July 
2, 2022. 
 
You asked the Plan to waive the copayment for the surgical preparation or creation of recipient site by excision 
of open wounds, and the adjacent tissue transfer or rearrangement. You say that this location is out-of-network, 
and you would never have used this provider if you were told by either the Plan or the provider. 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 30% 
coinsurance for out-of-network outpatient hospital ambulatory surgical centers.  
 You have been asked to pay $552.42 in coinsurance, which is 30% of the allowed amount for the surgical 
preparation or creation of recipient site by excision of open wounds, and the adjacent tissue transfer or 
rearrangement ($1,841.42 allowed amount x 30% coinsurance = $552.42). The surgical preparation or creation 
of recipient site by excision of open wounds, and the adjacent tissue transfer or rearrangement 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 the surgical preparation or 
creation of recipient site by excision of open wounds, and the adjacent tissue transfer, or rearrangement 
provided on July 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 test kits (87426) provided February 1, 2022. 
 
You asked the Plan to pay for the COVID-19 test kits. You say that the tests should be covered. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that starting April 4, 2022 people with Medicare Part 
B can get up to eight free over-the-counter tests for the month of April any time before April 30, and can then 
get another set of eight free over-the-counter tests during each subsequent calendar month through the end of 
the COVID-19 Public Health Emergency. 
 
We looked at the file and Medicare rules. The test kits were purchased prior to April 4, 2022. Based on this 
information, we decided that Medicare rules for coverage of the COVID-19 test kits have not been met. 
Therefore, we decided that the Plan does not have to pay for COVID-19 test kits (87426) provided February 1, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to get to your medical appointments. The Plan denied your request. The Plan says your benefit only allows 36 
trips for routine transportation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 the laboratory services provided on March 24, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan does not have to pay for exploration of spinal fusion provided to the enrollee on 
November 24, 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 Current Procedural Terminology (CPT) code 22830-59 (1 Unit) remains not supported 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 the services Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found the records 
do support that the exploration of spinal fusion (CPT 22830-59), was a separate and distinct procedure from the 
removal of anterior instrumentation. The operative report dated 11/24/21 corroborated that he underwent a 
plate removal from the previous fusion at C4-6. The side-to-side retractor blades were placed to visualize the 
disc space. The plate was removed. There has been significant bone growth from C3 vertebral body across the 
C3-C4 disc space that is removed and saved for some bone grafting. It was then noted that the fusion 
underneath it appeared solid. This in itself indicates that the observation or exploration of spinal fusion did 
occur after the plate removal. 
 
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 does not have 
to pay for exploration of spinal fusion provided to the enrollee on November 24, 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 inpatient rehabilitation to recover. The Plan 
denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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 the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy 
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.