Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hoyer lift (E0635). 
 
You asked the Plan to pre-approve a hoyer lift. You say that you cannot get out of bed with the lift. The Plan 
denied your request. The Plan says that clinical records do not show that you are confined to a bed. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of a lift can be covered if the beneficiary 
would be bed confined without it. 
 
We looked at the file and Medicare rules. The file does not include medical records indicating you are bed 
confined. Based on this information, we decided that Medicare rules for coverage of a hoyer lift have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a hoyer lift (E0635).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunohistochemistry or immunocytochemistry services 
(88341, 88342) provided on June 14, 2021. 
 
You asked the Plan to pay for services billed with codes 88341 and 88342. You say that these services are 
separate tests from 88360 and should be paid. The Plan denied your request. The Plan says a National Correct 
Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 88360 and codes 88341 and 
88342. These PTP edits each have a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with these PTP code edits. These services were not 
billed appropriately by Medicare coding regulations. 
 
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 
88341 and 88342 are both column II codes to column I code 88360. These services have 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 immunohistochemistry or 
immunocytochemistry services (88341, 88342) provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a wound care procedure performed on 
March 7, 2022. 
 
You asked the Plan to waive the copayment for the wound care. You say that you do not know why the 
procedure was not covered. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 
copayment for each outpatient hospital visit.  
 
You have been asked to pay $260.94, which is less than the $395 copayment for the wound care. The wound 
care 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 a wound 
care procedure performed on March 7, 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. You say that the enrollee needs admission into sub-acute 
rehabilitation. The Plan denied your request. The Plan says based on the information we have about the 
enrollee's condition they did not meet the requirements. 
 
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 was admitted for fractures of radius, ulna and pelvis after a fall.  
Medical problems are stable. Our physician reviewer found there are no complex nursing or rehabilitation 
needs. While you have a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
head provided on December 15, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were informed that there was no 
copayment for the service. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for advanced imaging services at an outpatient hospital, such as CT scans.  
 
You have been asked to pay a $110 copayment for the CT scan. The CT scan 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 copayment for a computed tomography (CT) scan of the head provided on December 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional occupational therapy (OT) visits. 
 
You asked the Plan to pre-approve additional OT visits. The Plan denied your request. The Plan says more 
skilled treatment is not needed at this time. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
  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 additional OT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. Our reviewer also found that the additional therapy services are not an appropriate duration and 
frequency for treatment of the enrollees medical condition and therefore are not medically 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 additional OT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional occupational therapy (OT) visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for laboratory services provided by an out-of-
network (OON) provider on January 5, 2022. 
 
You asked the Plan to waive the coinsurance for the OON lab services. You say that you were informed that 
the provider was in-network. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 40% 
coinsurance for lab services with an out-of-network (OON) provider. 
 
Service Allowed Amount 40% Coinsurance (OON) 
Laboratory $108.00 $43.20 
Laboratory $238.08 $95.23 
Total:  $138.43 
 
The file shows that the Plan determined the provider is out-of-network. Therefore, you have been asked to pay $138.43, which is 40% of the allowed amount for the OON lab services. The OON lab services fall 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 laboratory services provided by an out-of-network (OON) provider on January 5, 
2022.  
 
Your complaint about Plan representatives misinforming you of cost sharing 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 physician services (99233) provided June 5, 2021 to June 7, 
2021. 
 
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 records do not support the code 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 definition of code 99233 is hospital discharge day management. 
 
 
 
 We find that CPT code 99233 is not supported in the medical record. Specifically, the records do not include a 
note for discharge management of 31 minutes or more. 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 (99233) provided June 5, 2021 to June 7, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve medial branch blocks (MBB). 
 
You asked the Plan to pre-approve MBB. You say that medial branch blocks are medically necessary. The Plan 
denied your request. The Plan says that medial branch blocks do not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 medial branch blocks. Our reviewer 
says that medial branch blocks are medically necessary. Our physician reviewer found this would be the second 
confirmatory set of MBBs. The request is medically reasonable and 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 MBB have been met. Therefore, we decided that the Plan has to pre-approve 
medial branch blocks (MBB).  
 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 waive the copayment for an emergency room (ER) visit provided on 
April 3, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you had to go back twice due to a 
concussion. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency 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 an emergency room (ER) visit 
provided on April 3, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve intradialytic parental nutrition (IDPN). 
 
You asked the Plan to pre-approve IDPN. You say that the treatment is medically necessary. The Plan denied 
your request. The Plan says that the treatment is not currently appropriate for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 IDPN. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has documented poor appetite and is malnourished and cannot be reasonably felt to 
be able to adequately increase caloric intake.  The enrollee qualifies for continuation of IDPN as part of a 
comprehensive nutritional plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IDPN have been met. Therefore, we decided that the Plan has to pre-approve 
intradialytic parental nutrition (IDPN).  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the x-ray services provided on November 19, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the 
provider ID is either missing, incomplete, or invalid. 
 
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 file shows that the enrollee received a wrist x-ray. The facility claim provided includes a valid NPI for the 
facility and attending physician. 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 x-ray services provided on November 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 4, 2022, by an out-
of-network provider. 
 
You asked the Plan to pay for laboratory services. 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 laboratory services at issue in this appeal. The Plan did not pre-approve 
the laboratory services at issue. We found no exception that would require the Plan to pay for these laboratory 
services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on February 
4, 2022, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the member meets all applicable Medicare criteria 
for admission to an acute rehabilitation unit. The Plan denied your request. The Plan says based on Medicare 
guidelines, the Inpatient Rehabilitation Facility (IRF) services you are requesting do not meet the requirements 
for approval. 
 
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 the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transvaginal ultrasound provided on 
January 19, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the Plan should pay for this 
service. You say that you do not have a copayment. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $170 
copayment for each radiological diagnostic service, including ultrasounds.  
 
You have been asked to pay $114.31, which is less than the $170 copayment for the ultrasound. The 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 copayment for a transvaginal ultrasound provided on January 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued inpatient skilled nursing facility (SNF) care 
provided from January 14, 2022, through January 18, 2022. 
 You asked the Plan to pay for the SNF care. You say that continued inpatient skilled nursing facility care was 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee did not meet 
criteria for coverage of the continued inpatient skilled nursing facility care provided. 
 
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 pay for the continued SNF care. Our reviewer says 
that the continued inpatient skilled nursing facility care provided was not medically necessary. Our physician 
reviewer found that the enrollee did not require skilled nursing or skilled therapy services on a daily basis. 
Additionally, as a practical matter, the enrollee did not require the necessary services on an inpatient basis, only 
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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the continued inpatient skilled nursing facility (SNF) care provided from January 14, 2022, 
through January 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed.  
 
 
 
 
 
 Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 13, 
2021.