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

 
We decided that the Plan does not have to reduce the coinsurance for myocardial perfusion imaging provided 
on December 14, 2022. 
 
You asked the Plan to reduce the coinsurance for myocardial perfusion imaging. You say that you were told 
that the cost sharing would be lower. 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 20% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for myocardial perfusion imaging. This item/service 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. The total you owe is $291.62 ($1458.10 allowed 
amount x 20% = $291.62). Therefore, we decided that the Plan does not have to reduce the coinsurance for 
myocardial perfusion imaging provided on December 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Inpatient mental health care provided on 
September 07, 2022, to September 13, 2022. 
 
You asked the Plan to waive the copayment for Inpatient mental health care. 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 $1,590 
copayment for Inpatient mental health care. 
 
You have been asked to pay a $1,590 copayment for Inpatient mental health care. This item/service falls within 
the Inpatient mental health care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
Inpatient mental health care provided on September 07, 2022, to September 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary and mandibular complete dentures (D5110, 
D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the charges. 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 maxillary 
and mandibular complete dentures (D5110, D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says only the preferred brand products listed 
in the EOC are covered. 
 
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the CGM. Therefore, we decided that the Plan does not have to pre-approve a Dexcom continuous glucose 
monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 
07, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. 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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on October 07, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93010, 99156, 99291 rendered on June 18, 
2022. 
 
You asked the Plan to pay for the services. You say that the services 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 definition of the denied codes is: 
 
CPT 93010: 
 
Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only 
 
CPT 99156: 
 
Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the 
sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older 
 
CPT 99291: 
 
Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records provided 
does not include sufficient documentation to validate that the denied codes were rendered in this case. The 
codes are not supported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 93010, 99156, 99291 rendered on June 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the home ventilator is being requested for use in targeted tidal volume - pressure support (TTV-PS) mode which could be 
provided by a bilevel positive airway pressure (BiPAP) device with average volume assured pressure support 
(AVAPS) and a back-up rate. Provided records do not document trial and failure of a BiPAP device with 
AVAPS and a back-up rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 29, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on November 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute 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 that the admission to an IRF is not medically necessary. 
 
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 the enrollee does not have complex nursing or rehabilitation needs. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that the enrollee 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the hernia repair surgery provided on 
November 14, 2022, to November 16, 2022. 
 
You asked the Plan to reduce the coinsurance for the hernia repair surgery. You say that this should not be 
considered an outpatient hospital charge and should only have a $75 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 20% 
coinsurance for outpatient surgery at an outpatient hospital facility. 
 
You have been asked to pay 20% coinsurance for the hernia repair surgery. This item/service falls within the 
outpatient surgery at an outpatient hospital facility 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 total you owe is $984.03 ($4,920.15 allowed amount x 20% 
coinsurance = $984.03). Therefore, we decided that the Plan does not have to reduce the coinsurance for the 
hernia repair surgery provided on November 14, 2022, to November 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on December 15, 
2022. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that it is the responsibility of the facility 
to obtain referrals. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a skilled nursing facility 
visit provided on December 15, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) 
provided on September 13, 2022, to September 14, 2022. 
 
You asked the Plan to waive the copayment for the esophagogastroduodenoscopy (EGD). You say that the 
copayment amount is too much for the care you received. 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 $200 
copayment for outpatient surgery. 
 
You have been asked to pay a $200 copayment for the esophagogastroduodenoscopy (EGD). This item/service 
falls within the outpatient surgery 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 records show you are not being charged for the observation services. 
Therefore, we decided that the Plan does not have to waive the copayment for the 
esophagogastroduodenoscopy (EGD) provided on September 13, 2022, to September 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
August 29, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for emergency room services. This item/service 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 emergency room services 
provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
July 22, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that these services should e covered 
and no authorization is needed. The Plan denied your request. The Plan says the billed codes are invalid for 
Medicare purposes. 
 
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 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 18, 2022. 
 
You asked the Plan to pay for an office visit. You say that this is a returning patient and you are requesting 
reconsideration of payment. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on November 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652), segmental pneumatic 
appliance for use with pneumatic compressor, full leg (E0667), and segmental pneumatic appliance for use 
with pneumatic compressor, trunk (E0656). 
 
You asked the Plan to pre-approve a pneumatic compressor, full leg segmental pneumatic appliance, and trunk 
segmental pneumatic appliance. You say that the services are necessary. The Plan denied your request. The 
Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PCDs coded as E0650, E0651, E0652 are used only 
in the treatment of lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers. 
 
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 a pneumatic compressor, full leg 
segmental pneumatic appliance, and trunk segmental pneumatic appliance. Our reviewer says that the services 
are not medically necessary. Our physician reviewer found based on the medical records provided there is no 
documentation that the pneumatic compression device and associated appliances at issue in this case meet all of 
Medicare's LCD criteria for medically reasonable and necessary for the enrollee. Provided records in this case 
do not document at least four weeks of regular, daily, multiple-hour home usage of a basic pump (E0650 or 
E0651) after careful, in-person fitting, training and supervision by a technician who is skilled in and who 
regularly and successfully uses the appliance provided as required by the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a pneumatic compressor, full leg segmental pneumatic appliance, and trunk 
segmental pneumatic appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor (E0652), segmental pneumatic appliance for use with pneumatic compressor, 
full leg (E0667), and segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for air ambulance services provided on July 
19, 2022. 
 
You asked the Plan to waive the coinsurance for air ambulance services. You say that you disagree with the 
coinsurance. 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 20% 
coinsurance for ambulance services/air ambulance. 
 
You have been asked to pay 20% coinsurance for air ambulance services. This item/service falls within the 
ambulance services/air ambulance 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 
air ambulance services provided on July 19, 2022.