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

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 
20, 2022, to May 23, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were in the emergency 
room (ER) and was never inpatient. The Plan denied your request. The Plan says the copayment applied 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 $325 
copayment per day for days 1 through 5 for covered hospital care. 
 
You have been asked to pay $650 ($325 x 2 days) copayment for inpatient hospital care. Inpatient hospital care 
falls within the Inpatient Hospital 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 hospital care provided from May 20, 2022, to May 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 17, 
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 May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on October 26, 2021. 
 
You asked the Plan to pay for foot orthotics. 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 foot orthotics provided on October 26, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 25, 
2022. 
 
You asked the Plan to pay for procedure code 88341. You say that you have provided records to support the 
service billed. The Plan denied your request. The Plan says payment for code 88341 is bundled into payment 
for code 88360. 
 
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 88341 
is a column II code to column I code 88360. 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 88341 billed for date of service February 25, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (code D0150) you received on 
May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that the only reason you had to have this oral exam 
was because you had to switch dentists. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 19, 2021. This 
limitation applies regardless of the reason for the service. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral exam (code D0150) you received on May 24, 2022.  
 Your complaint about being overcharged by your previous dentist is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on April 13, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
 
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 domiciliary or rest home visit provided on April 
13, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical records. 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, for 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 provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiological supervision services coded 75630-26-XU
provided on February 28, 2022.

You asked the Plan to pay for the radiological supervision services as billed. You say that you would like this
claim reprocessed based on the medical records. The Plan denied your request. The Plan says procedure code
75630 is considered inclusive to 37225 and no separate payment will be made.

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 75630 is a column II code to column I code 37225; however, 75630
was billed with a modifier.

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 the radiological supervision services as billed. Our reviewer
says that the documentation does not support separate payment for 75630-26-XU. Our reviewer found the
medical documentation does not support the use of procedure code 75630 as the procedure is inclusive to
procedure 37225. Even with XU modifier it would not be appropriate in this case as the procedure was
performed on the same laterality and was not distinct or separate. The documentation does not support the use
of the XU modifier to bypass the NCCI edit.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the radiological supervision services as billed have not been met. Therefore, we
decided that the Plan does not have to pay for the radiological supervision services coded 75630-26-XU
provided on February 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the device evaluation services provided on April 19, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee gets this checked every week. 
The Plan denied your request. The Plan says that the code can be billed once every 90 days. 
 
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. 
 
We looked at the file and the rules. The Local Coverage Article, A56602, the Plan used in their decision to 
deny services is not binding in this case. The rule does not have Medicare Part B jurisdiction where the services 
were provided. The National Coverage Determination says that how often a pacemaker should be monitored is 
the responsibility of the physician and may vary over time. 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 device evaluation services provided on April 19, 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 pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF services is the appropriate level of care for 
the enrollee and delay in admission would have an impact on the enrollee's safety. The Plan denied your 
request. The Plan says the records do not show the enrollee needs to be seen by a rehabilitation doctor at least 3 
times a week for evaluation of functional and medical goals and progress according to the records sent by their 
provider. The services the enrollee needs can be provided safely in other settings like a skilled nursing facility, 
home with home health services or 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 in this case, the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this individual will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an inpatient rehabilitation facility. 
 
The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesnt support that they would meet criteria for 
admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require 
skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision 
of a physician with at least 3 visits weekly to regain or maintain their functional status. The enrollee can 
receive further services at a lower level of 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a gym membership purchased on April 14, 2022. 
 
You asked the Plan to pay more for a gym membership. You say that you submitted almost identical receipts 
for the 2021 and the 2022 reimbursements. You also say you received $150 for 2021, and only $119.25 for 
2022. The Plan denied your request. The Plan says you were reimbursed $119.25 for the eligible months of 
2022. The Plan also says that you cannot be reimbursed for the months in 2023 because it is before the eligible 
timeline for filing. 
 
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 Plan covers gym benefits 
only when it is within the calendar year of the EOC. 
 
   
The Plans rules for additional coverage of gym benefits have not been met because the Plan cannot pay for 
months in 2023. Therefore, we decided that the Plan does not have to pay more for a gym membership 
purchased on April 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87653, 87798 billed for date 
of service January 7, 2022. 
 You asked the Plan to pay for procedures code 87481, 87640, 87653, 87798. You say that these services were 
medically necessary. The Plan denied your request. The Plan says payment for code 87481, 87640, 87653, 
87798 is bundled into payment for code 87150. 
 
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 codes 
87481, 87640, 87653, 87798 are column II codes to column I code 87150. 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 codes 87481, 87640, 87653, 
87798 billed for date of service January 7, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the eye exam (92014) provided on April 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that you have a medical issue with your eyes, and need 
them checked every few months. The Plan denied your request. The Plan says that you had reached your 
annual maximum $5,000 OON allowance for your point of services benefit. 
 
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. According to your 2022 Evidence of Coverage, you have a POS coverage limit 
of $5,000 per calendar year for out-of-network services. You are responsible for the full cost of services 
provided out-of-network once this limit is reached. The Plan did not provide any documentation showing your 
POS coverage limit has been exhausted. Therefore, we decided that the Plan has to pay for the eye exam 
(92014) provided on April 11, 2022, by an out-of-network (OON) provider.  
 
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 pay for physician's services provided on February 24, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Medicare is the 
payor of last resort. 
 
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. As the secondary insurer, the Plan 
cannot be held responsible for physician's services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for physician's services provided on 
February 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on May 
21, 2022, to May 27, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you do not believe you 
received all of the services listed on your bill, so this amount should not apply The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 
copayment for inpatient hospital services per day for days 1 through 5. 
 
You have been asked to pay a $395 copayment for inpatient hospital services. This item/service falls within the 
inpatient hospital services per day for days 1 through 5 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. The per-day copayment applies regardless of the extent of 
services you receive while you are an inpatient.  You were in the hospital for six days, so you were charged a 
$395 copayment for each day of the first five days, for a total of $1975.  Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services 
provided on May 21, 2022, to May 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stellate ganglion block (64510). 
 
You asked the Plan to pre-approve the injection. You say that this block is supposed to be for your anxiety and 
is not for treatment of pain. The Plan denied your request. The Plan says the requested service is not medically 
necessary. 
 
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 the injection. Our reviewer says that the 
requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested service is considered experimental at this time. Therefore, the reviewer found that the 
requested service is not medically reasonable or 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a stellate ganglion block (64510).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on March 7, 2022. 
 
You asked the Plan to pay for the testing services. You say that PCR testing is medically necessary to identify 
the causative organism. The Plan denied your request. The Plan says the testing exceeded the enrollee's medical 
needs. 
 
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 pay for the testing services. Our physician reviewer 
found that a sample of the left hallux toenail was provided to evaluate for pathogens. Currently, standard of 
care is potassium hydroxide (KOH) and a fungal culture. A KOH test is a standard of care for testing toenails 
for onychomycosis as that they reveal fungal hyphae. A fungal culture is standard of care for determining 
onychomycosis in that it will allow for determining the exact pathogen. It appears that the PCR testing 
exceeded this enrollees needs. Therefore, the panel testing (PCR) performed on the left hallux toenail is not 
medically reasonable or necessary to treat the enrollees condition. 
 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 testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the panel testing provided on March 7, 2022.