Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan 
denied your request. The Plan says that documentation does not support you require intensive therapy for 3 
hours a day at least 5 days per week and that care is too complex to be provided at a lower level of care. 
 
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. You 
are functioning near a home care level of function and does not require intensive rehabilitation or frequent physiatry oversight. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from June 3, 
2021, to June 14, 2021, billed with code KDXE1. 
 
You asked the Plan to pay for SNF care billed with code KDXE1. You say that this care was medically 
necessary, and all services/conditions were reported correctly. The Plan denied your request. The Plan says the 
records provided do not support the use of the "D" character for the second letter of the PDPM code. The 
services provided are better represented with "A" in this case, for a code of KAXE1. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report SNF services with the appropriate HIPPS code. The rules also say that as the last day of 
the look-back period, the Assessment Reference Date (ARD) serves as the reference point for determining the 
care and services captured on the Minimum Data Set (MDS) assessment. Anything that happens after the ARD 
will not be captured on that MDS. 
 
We looked at the file and Medicare rules. The record shows that the MDS assessment for the relevant section 
was signed and dated on June 11, 2021, which is after the ARD date of June 7, 2021. Based on this 
information, we decided that Medicare rules for coverage of SNF care billed with code KDXE1 have not been 
met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services 
provided from June 3, 2021, to June 14, 2021, billed with code KDXE1.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you are not affiliated with any other medical plan. 
The Plan denied your request. The Plan says the provider is out of network, there is no pre-authorization 
process, no referral from the primary physician, no medical emergency, and there are eight contracted 
providers in your living area. 
 
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 psychotherapy provided on May 9, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mental health visit provided on April 4, 
2022. 
 
You asked the Plan to waive the copayment for mental health visit. You say that you should not have a 
copayment. 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 $40 
copayment for a mental health visit in a specialists office.  
 
You have been asked to pay $40 copayment for mental health visit. Mental health visits fall within the 
Outpatient 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 
mental health visit provided on April 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you have no current skilled therapy or skilled nursing service needs. 
 
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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. You 
do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily 
skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of 
your condition. Our physician reviewer found that your condition does not meet Medicare criteria for continued 
SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning (99497) provided on December 17, 
2021, and hospital discharge day management (99239) provided on December 18, 2021. 
  You asked the Plan to pay for advance care planning (99497) and hospital discharge day management (99239). 
You say that the services were medically necessary, and the attached medical records supports the claim as 
originally submitted. You say that the records should be reviewed, and the claim reprocessed. The Plan denied 
your request. The Plan says procedure code 99497 is inclusive to procedure code 99223 and procedure code 
99239 is not supported by the records submitted. 
 
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 99497 is a column II code to column I code 99223. Procedure code 
99497 has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, 
Medicare billing criteria for procedure code 99497 have not been met. In addition, we find that CPT code 
99239 is not supported in the medical record. Specifically, the records do not document discharge management 
services of more than 30 minutes as required by the CPT code billed.  
 
Based on this information, we decided that Medicare rules for coverage of advance care planning (99497) and 
hospital discharge day management (99239) have not been met. Therefore, we decided that the Plan does not 
have to pay for advance care planning (99497) provided on December 17, 2021, and hospital discharge day 
management (99239) provided on December 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance transport and ground mileage 
provided on March 28, 2022. 
   
You asked the Plan to pay for non-emergency ambulance transport and ground mileage. You say that this 
member had three trips in the same day and the Plan has denied all three ambulance transports. The Plan denied 
your request. The Plan says the information provided at the time of the appeal does not support ambulance 
transport. The Plan also says that a physician's office is not a covered destination for non-emergency situations. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for non-emergency ambulance transport and ground 
mileage provided on March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99285) provided on February 5, 
2022. 
 
You asked the Plan to pay for the emergency room visit. You say that this service was medically necessary. 
The Plan denied your request. The Plan says code 99285 is not supported. 
 
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 99285 is Emergency department visit, for the evaluation 
and management of a patient, which requires these 3 key components: a comprehensive history, a 
comprehensive examination, and medical decision making of high complexity. 
 
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 emergency room visit. Our reviewer says that the records 
do not support the code billed. Our reviewer found the records show the patient suffered a fall, was treated and 
released. Records show there was only moderate level decision-making. 
 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 emergency room visit have not been met. Therefore, we decided that the 
Plan does not have to pay for an emergency room visit (99285) provided on February 5, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient mental health services on 
December 02, 2021, to February 03, 2021. 
 
You asked the Plan to waive the coinsurance for outpatient mental health services. You say that you want to 
appeal the amount being charged. The Plan denied your request. The Plan says the cost sharing you are being 
charged 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 a 30% 
coinsurance for out-of-network mental health service. 
 covered services include mental health services provided by a state-licensed psychiatrist or doctor, clinical 
psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other 
Medicare-qualified mental health care professional as allowed under applicable state laws. For dates December 
02, 2021, to February 03, 2022, the provider billed in the amount of $65 and the allowed is $48.75. $48.75 x 
30% = $14.62. There were 9 dates of service. $14.62 x 9 = $131.58. 
 
You have been asked to pay a 30% coinsurance for outpatient mental health services. Outpatient mental health 
services falls within the Outpatient 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 
coinsurance for outpatient mental health services on December 02, 2021, to February 03, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the medical eye exam (92014) and refraction (92015) 
provided on May 10, 2022. 
 
You asked the Plan to pay more for the medical eye exam (92014) and refraction (92015). You say that this is 
the same annual visual examination that you have received every year. You also say that the Plan has always 
paid for this service without fail. The Plan denied your request. The Plan says the the copayment applied 
correctly to the eye exam and refractions are not covered. 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The rules say that refractive procedures are not covered even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. 
 
You have been asked to pay a $25 copayment for the medical eye exam and the full cost of the refraction as it 
is not a covered benefit. The medical eye exam falls within the Vision Services (Medicare-Covered) benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
Therefore, we decided that the Plan does not have to pay more for the medical eye exam (92014) and refraction 
(92015) provided on May 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection (ES) lumbar spine (62323). 
 
You asked the Plan to pre-approve the injections. You say that please see the attached documentation for the 
procedure scheduled on August 18, 2022, which was denied The Plan denied your request. The Plan says the 
ESI lumbar spine is not reasonable or necessary at this time. 
 
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 injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the request does not meet the LCD requirements for the service. The enrollee has a history of a 
previous lumbar surgery L5-S1 (exact procedure not known). There is no documentation of advanced imaging 
or correlating symptoms on exam as required by the LCD. Therefore, at this time, the request is considered 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve epidural steroid injection (ES) lumbar spine (62323).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI for the enrollee. 
 
You asked the Plan to pre-approve an MRI. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that there is no reason that a conventional CT scan cannot be used. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI. Our reviewer says that an MRI 
is not medically reasonable and necessary. While several international societies recommend a surveillance 
program for individuals at risk for developing pancreatic cancer, the actual efficacy of such preventive 
programs has not been validated so far. Our physician reviewer found that the enrollee's condition does not 
meet criteria for coverage of an MRI. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an MRI for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on January 18, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet rich plasma injections. 
 
You asked the Plan to pre-approve platelet rich plasma injections. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 platelet rich plasma injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested procedure is considered an experimental/investigation 
approach without proven efficacy. Therefore, the request is deemed 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 platelet rich plasma injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve platelet rich plasma injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 20, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this provider is a non-network provider who does not work with the 
member's health plan, and the member was referred by a provider who also does not work with the member's 
plan. 
 
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 laboratory services provided on July 20, 2021, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the prosthetic device that was billed on the 
claim for March 14, 2022, to March 17, 2022. 
 
You asked the Plan to waive the coinsurance for the prosthetic device. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says the cost share has been applied 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 20% 
coinsurance for a Medicare-covered prosthetic device and related supplies provided in-network.  
 
You have been asked to pay $2435.96 for the prosthetic device. A prosthetic device falls within the Prosthetic 
Devices and Related 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 the 
prosthetic device that was billed on the claim for March 14, 2022, to March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 3, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 99100 is 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 code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 3, 2022.