Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 30, 2021 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 it was 
determined these services can be received in-network. 
 
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 September 30, 2021 by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve three additional chiropractic visits. 
 
You asked the Plan to pre-approve three additional chiropractic visits. You say that you need the additional 
visits. The Plan denied your request. The Plan says that your chiropractic benefit has been exhausted and 
additional routine chiropractic visits are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not submit documentation showing that 30 visits have 
already been provided and approved. This means that we cannot determine if your 30-visit chiropractic benefit 
has been exhausted. It is the burden of the Health Plan to substantiate their decision with evidence. In this case, 
the decision has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has 
to pre-approve three additional chiropractic visits.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the denial of authorization for IRF care is correct. 
 
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's nursing, medical, and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee may need physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on October 11, 2021. 
 
You asked the Plan to waive the coinsurance for injections. You say that you should not have a coinsurance 
share as you have had this injection before without receiving a charge. The Plan denied your request. The Plan 
says the coinsurance amount applied was 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 20% 
coinsurance for in-network Part B prescription drugs. The allowed amount of this drug is $2790.81 resulting in 
a coinsurance amount of $487.60.  
 
You have been asked to pay 20% coinsurance for injections. Injections fall within the In-Network Part B 
Prescription Drugs 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 injections provided 
on October 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast tomosynthesis screening (77063) and 
mammography screening (77067) provided on April 12, 2022, and the ultrasounds (76830 & 76856) provided 
on April 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the breast screening, mammography, and ultrasounds. You say that you are on a 
fixed income and would like the Plan to waive your cost share charges. The Plan denied your request. The Plan 
says the services were provided out-of-network and were not approved in advance. 
 
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 the breast tomosynthesis screening (77063) and 
mammography screening (77067) provided on April 12, 2022, and the ultrasounds (76830 & 76856) provided 
on April 23, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (interlaminar 
approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, 
facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT), single 
or multiple levels, unilateral or bilateral; lumbar (0275T). 
 
You asked the Plan to pre-approve the minimally invasive back surgery. You say that you are appealing the 
decision. You do have spinal stenosis and your MRI from 10/21/12021 shows you have stenosis. The Plan denied your request. The Plan says the records do not show that the enrollee meets the criteria for the requested 
procedure. 
 
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 minimally invasive back surgery. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has low back pain related to spinal stenosis of the lumbar 
region. She had tried medications, physical therapy, and prior surgery (bilateral L5-S1 discectomy and 
foraminotomy). The MRI from 2021 showed minimal disc bulge with no significant canal stenosis, normal 
foramina, mild facet arthropathy, mild retrolisthesis and disc osteophytes, and moderate foraminal stenosis 
without compromise of nerve roots. However, the MRI does not correlate with the enrollee's symptoms and 
does not show an objective finding of stenosis or any other finding that requires surgery at this time. Without 
MRI support or enrollment in a clinical trial (no documentation of such), the criteria is not met and the 
procedure will be considered 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 the minimally invasive back surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (interlaminar approach) for 
decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or 
foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT), single or multiple levels, 
unilateral or bilateral; lumbar (0275T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953), 
guided tissue regeneration (D4266), and gingival irrigation (D4921). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says the requested dental services are not listed as covered by the supplemental 
dental coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
replacement graft for ridge preservation (D7953), guided tissue regeneration (D4266), and gingival irrigation 
(D4921).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that clinical information was submitted to support 
medical necessity. The Plan denied your request. The Plan says additional physical therapy visits are not 
medically necessary. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent slow deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee is independent in a home exercise program. 
Our physician reviewer also found that the documentation does not support the need for ongoing skilled 
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 therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 physical therapy visits.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the simple repair of superficial wounds (12001) provided on October 1, 
2021. 
 
You asked the Plan to pay for the simple repair of superficial wounds (12001). You say that this service was 
appropriately billed per CPT and CMS guidelines. You say that the attached medical records support the visit. 
The Plan denied your request. The Plan says that procedure code 12001 is included in the global surgery 
package of procedure code 28490. 
 
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 12001 is simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or 
extremities (including hands and feet); 2.5 cm or less. 
 
We find that CPT code 12001 is supported in the medical record. Specifically, the medical records show the 
wound repair was on the left shoulder. This would be unrelated to the treatment of left finger received on 
September 5, 2021, and global surgery rules would not apply. Based on this information, we decided that 
Medicare rules for coverage of the simple repair of superficial wounds (12001) have been met. Therefore, we 
decided that the Plan has to pay for the simple repair of superficial wounds (12001) provided on October 1, 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $480 copayment for outpatient mental health visits from 
January 7, 2022, to March 15, 2022. 
 
You asked the Plan to waive the $480 copayment for outpatient mental health visits from January 7, 2022, to 
March 15, 2022. You say that you cannot afford to pay this. The Plan denied your request. The Plan says you 
must pay a $40 copayment for each outpatient individual or group visit. 
 
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 per individual or group visit for Outpatient Mental Health Care.  
 
 You have been asked to pay a $480 copayment for outpatient mental health visits from January 7, 2022, to 
March 15, 2022. Outpatient mental health visits fall within the Outpatient Mental Health Care benefit category. 
You had 12 outpatient mental health visits from January 7, 2022, to March 15, 2022. $40 x 12 = $480. 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 $480 copayment for outpatient mental health visits from January 7, 2022, 
to March 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport and mileage provided on August 26, 
2021. 
 
You asked the Plan to pay for the ambulance transport and mileage. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services provided are included in the 
inpatient payment. 
 
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 codes A0427 and A0425 are not supported in the medical record. Specifically, the enrollee 
was in an inpatient stay during this date of service. This means that payment for these services should be 
included in the payment for the inpatient services. This means these services are not separately payable. Based 
on this information, we decided that Medicare rules for coverage of the ambulance transport and mileage have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transport and mileage 
provided on August 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy (NPWT) pump. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that NPWT pumps are covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found based on the most recent records, the 
enrollee's wound does not appear to be appreciably changing. The wound measurements from May 5, 2022 are 
similar to those of July 18, 2022.  Given the lack of improvement and duration of use well beyond the four-month time frame, continued NPWT 
use is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a negative pressure wound therapy (NPWT) pump.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on November 
29, 2021, and February 28, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that these services were performed 
in the doctors office, therefore you should not have a copayment. The Plan denied your request. The Plan says 
the coinsurance 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 $350 
copayment for Medicare-covered surgery services at a hospital outpatient facility.  
 
You have been asked to pay a total of $700 for the outpatient surgeries ($350/surgery x 2 surgeries = $700). 
Outpatient surgery falls within the Outpatient Hospital 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 outpatient surgery provided on November 29, 2021, and February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Donjoy Sully shoulder brace. 
 
You asked the Plan to pre-approve these services. You say that you need the brace to stabilize your shoulder 
and provide a greater range of motion than a rigid brace. The Plan denied your request. The Plan says the 
services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that covered prosthetics and braces include rigid and 
semi-rigid devices. 
 
We looked at the file and Medicare rules. The file shows that the requested brace is not a rigid or semi-rigid 
device. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Donjoy Sully shoulder brace.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on January 12, 
2022. 
 
You asked the Plan to pay for the critical care services. You say that you would like this claim reprocessed 
based on the submitted medical records. The Plan denied your request. The Plan says the documentation 
submitted does not support the billed services. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation 
that between 30-74 minutes were spent providing the critical care services. Based on this information, we 
decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided 
that the Plan does not have to pay for the critical care services (99291) provided on January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you have several conditions for which the PWC 
is needed. The Plan denied your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The records do not show that you have a mobility limitation that is due to a neurological condition, myopathy 
or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 
power wheelchair (PWC).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 88341, 88342, 88360, and 
88381 provided on July 29, 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 are not payable 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 codes 88341, 88342, 88360, and 88381 are not supported in the medical record. Specifically, 
these codes have a status code of 1. These services were not billed with an appropriate modifier to be paid for 
the professional component/technical component. Based on this information, we decided that Medicare rules 
for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services coded 88341, 88342, 88360, and 88381 provided on July 29, 2021.