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

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
November 11, 2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that your husband had the same blood 
work without a copayment. You also say this should have a $0 copayment due to it being preventative testing. 
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 $10 
copayment for Medicare-covered laboratory tests.  
 
The record shows this claim was approved and you are responsible for the cost share amount. You have been 
asked to pay a $10 copayment for the lab services. This item/service falls within the outpatient diagnostic tests 
and therapeutic 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 the 
laboratory services provided on November 11, 2022.
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 you need additional therapy and are able to do three 
hours a day. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been 
met. 
 
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 documentation does not support necessity for admission to an IRF due to the 
lack of acute medical illness or medical complexity and lack of skilled rehabilitation nursing needs. While you 
may benefit from physical and occupational therapy, your rehabilitation needs can be provided in a lower 
intensity and alternate setting such as in home with continued therapy. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 25, 
2022 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the copayment. 
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 $125 
copayment for outpatient diagnostic tests/Medicare-covered radiological diagnostic services.  
 
You have been asked to pay a $125 copayment for an ultrasound. However, you are being asked to pay 
$100.53 which is less than the required amount. This item/service falls within the outpatient diagnostic 
tests/Medicare-covered radiological diagnostic 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 an ultrasound provided on October 25, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network behavioral health visits 
provided on January 26, 2022, to May 31, 2022. 
 
You asked the Plan to waive the copayment for behavioral health office visits. You say that that you were told 
that your appointments were considered in-network can be covered 100%. 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 $40 
copayment for each out-of-network Medicare-covered outpatient mental health therapy visit.  
 
You have been asked to pay a $40 copayment for each behavioral health office visits. You have been asked to 
pay a total of $520 (13 services x $40 copayment = $520 copayment). This item/service falls within the out-of-
network Medicare-covered outpatient mental health therapy visit 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 out-of-network behavioral health visits provided on January 26, 2022, to May 31, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal system, below knee, alignable 
system (L5910). 
 
You asked the Plan to pre-approve an alignable system. You say that an alignable system is medically 
necessary to ensure proper fit and function of the prosthesis. The Plan denied your request. The Plan says the requested item exceeds the standard of care. The Plan also says that the documentation does not indicate why 
the enrollee's current alignable system cannot be used. 
 
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 an alignable system. Our reviewer says 
that the requested alignable system is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not indicate why the current alignable system 
cannot be used. The reviewer found that the advantage of an alignable system has not been established with 
clear evidence. Therefore, the reviewer found that the requested alignable system 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 an alignable system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an addition, endoskeletal system, below knee, alignable system (L5910).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on September 18, 2022. 
 
You asked the Plan to waive the copayment for an ambulance transportation. You say that you cannot afford 
the copayment. 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 $440 
copayment for ground ambulance services.  
 
You have been asked to pay a $440 copayment for an ambulance transportation. This item/service falls within 
the ground 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 
ambulance transportation services provided on September 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a water circulating pump (E0236RR). 
 
You asked the Plan to pre-approve a water circulating pump. You say that the item is necessary. The Plan 
denied your request. The Plan says because a water circulating heating pad system is not medically necessary, a 
replacement pump is denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that because a water circulating heating pad system is 
not medically necessary, a replacement pump or pad will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a water circulating pump have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a water circulating pump (E0236RR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4300 and A4550 billed for date of service 
August 3, 2022. 
 
You asked the Plan to pay for procedure codes A4300 and A4550. The Plan denied your request. The Plan says 
procedure codes A4300 and A4550 are considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure codes A4300 and A4550 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes A4300 and A4550 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes A4300 and A4550 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes A4300 and A4550 billed for date of service 
August 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service December 9, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim denied as a duplicate in error. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service December 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral surgeon visit. 
 
You asked the Plan to pre-approve the oral surgeon visit. You say that you are requesting an out-of-network 
visit with an oral surgeon. You also say that you have a cracked tooth. The Plan denied your request. The Plan 
says dental services from an out-of-network provider are not covered by your supplemental benefits. 
 
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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve an oral 
surgeon visit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive sacroiliac (SI) joint fusion surgery 
(27279). 
 
You asked the Plan to pre-approve the surgical procedure. You say that please review for appeal of denial of SI 
joint procedure. The Plan denied your request. The Plan says the medically necessary criteria has not been met. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding imaging or radiographic evidence 
supporting a sacroiliitis pathology. There were no diagnostic imaging studies provided for review. There is no 
clear history of SI joint pain onset or failure of conservative treatment directed to the SI joint (outside of 
injections.) Multiple other plausible pain generators including at the lumbosacral spine are evident. There are 
limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested minimally invasive sacroiliac (SI) joint fusion (CPT 27279), in this case, 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve minimally invasive sacroiliac (SI) joint fusion surgery (27279).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) and 
appliance (E0673) provided on July 20, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) (E0675) and appliance (E0673) provided on July 20, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis provided on October 27, 2022. 
 
You asked the Plan to pay for the ankle foot orthosis. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the documentation submitted did not sufficiently support the billed 
supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the medical record must contain sufficient documentation of the 
enrollee's medical condition to substantiate the necessity of the items provided. The documentation does not 
support the necessity of the billed supply code. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
ankle foot orthosis provided on October 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says criteria for admission 
to the Acute Inpatient Rehabilitation setting have not been met, the enrollee's ongoing skilled therapy and 
nursing needs can be provided at a lower level of care such as at a Skilled Nursing Facility, on an intermittent 
basis at home with home health care, or in a long-term care setting. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an admission to inpatient detoxification services at a 
non-Medicare certified facility. 
 
You asked the Plan to pre-approve an admission to inpatient detoxification services at a non-Medicare certified 
facility. The Plan denied your request. The Plan says the requested facility is not certified or eligible to be 
certified as a Medicare approved facility for the level of care requested. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an admission to inpatient detoxification services at a non-Medicare certified facility have not been 
met. This provider is not part of the Medicare program and is not payable. Therefore, we decided that the Plan 
does not have to pre-approve an admission to inpatient detoxification services at a non-Medicare certified 
facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alginate or other fiber gelling dressing (A6196) and foam 
dressing (A6212) provided on June 29, 2022. 
 
You asked the Plan to pay for the alginate or other fiber gelling dressing and foam dressing. You say that this 
claim should be paid. The Plan denied your request. The Plan says services/supplies are not separately 
reimbursable. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
 
  Records show that the alginate or other fiber gelling dressing and foam dressing were used in a SNF or 
hospital. Therefore, we decided that the Plan does not have to pay for the alginate or other fiber gelling 
dressing (A6196) and foam dressing (A6212) provided on June 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 24301 & 23020 provided on October 20, 
2022. 
 
You asked the Plan to pay for procedure codes 24301 & 23020. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the records do not support the services billed. 
 
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 definitions of codes 24301 & 23020 are single muscle or tendon transfer of 
the upper arm or elbow of any type and a capsular contracture release. 
 
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 codes 24301 & 23020. Our reviewer says that the 
records do not support the billed service. Our reviewer found codes 24301 and 23020 are inclusive to code 
23472 that was also billed. The records do not support that these services were separate procedures. 
 
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 codes 24301 & 23020 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 24301 & 23020 provided on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on November 30, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a telehealth visit. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the enrollee must get care from 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 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 telehealth visit provided on November 30, 2022, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99213) provided on September 14, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99213 is not supported in the medical record. Specifically, this evaluation and 
management service is included in the global surgery period for code 92960 that was performed on the same 
date of service. No modifier was billed to denote a separate and distinct service. 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 (99213) provided on September 14, 2022.