Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an 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 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 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 this 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 an IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for complete ultrasound study of arm and leg 
arteries (CPT code 93923 X2) and testing of autonomic (sympathetic) nervous system function (95923) 
provided on April 27, 2022. 
 
You asked the Plan to waive the copayment for the services. You say that you do not think many of the billed 
services were done. 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). Review of the file shows that the total $155 was applied correctly to your cost-share for the services you 
received on April 27, 2022. For service 95923 the provider billed the Plan in the amount of $249.56 and the 
allowed amount was $106.06. Per the Plans benefits you are responsible for a copayment of $30.00 for non-
radiological diagnostic service per day or stay. Therefore, you are held liable for $30.00 copayment that has 
applied. For service 93923 the provider billed the Plan in the amount of $253.70 and the allowed amount was 
$107.82. Per the Plans benefits you are responsible for a copayment of $125.00 for radiological diagnostic 
service per day or stay. Therefore, you will only be held liable for the lower allowed amount of $107.82 
copayment for services received as Medicare works of the lessor of logic. For service 93923 the provider billed 
the Plan in the amount of $253.70 and the allowed amount was $107.82. Per the Plans benefits you are 
responsible for a copayment of $125.00 for radiological diagnostic service per day or stay. Therefore, you will 
only be held liable for a copayment of $17.18 as you already had the diagnostic service 93923 listed above 
which accrued the copay of $107.82 and as these radiological diagnostic tests work per day or stay, the Plan 
cannot bill over the $125.00 Benefit level. ($125.00 -107.82 = $17.18 copayment). $0.90 sequestration applied. 
The total copayment amount of $155.00 ($30.00 + $107.82 + $17.18 = $155.00) applied correctly per your 
2022 EOC. 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 complete ultrasound study of arm and leg 
arteries (CPT code 93923 X2) and testing of autonomic (sympathetic) nervous system function (95923) 
provided on April 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on June 20, 2021, through 
June 25, 2021. 
 
You asked the Plan to pay for inpatient hospital care. You say that they submitted documentation for 
reconsideration of DRG adjustment. The Plan denied your request. The Plan says there is insufficient 
documentation supporting the code. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of inpatient hospital care have been met. 
Medical records were not provided to verify the inpatient stay and if it was billed correctly. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided on June 20, 2021, through June 
25, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service April 28, 
2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says no separate payment is made. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that the 
code is not separately payable. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99053 billed for date of service April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care (99305) provided on July 20, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that this service should be covered. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. 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 initial nursing facility care (99305) provided on July 20, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93978 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code 93978. The Plan denied your request. The Plan says payment for 
code 93978 is bundled into payment for code 93975. 
 
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 93978 
is a column II code to column I code 93975 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 93978 billed for date of service August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on August 25, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician service. You say that due to the short time period, we were unable 
to get the authorization for the date of service in this case. You also say that the service was medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. 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 office visit (99214) provided on August 25, 2022, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for hospital outpatient services provided on 
July 14, 2022. 
 
You asked the Plan to waive the coinsurance for hospital outpatient services. You say that you are disputing the 
share cost. 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 and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers. The allowed amounts of these services total $16,936.42, resulting in a total 
coinsurance amount of $3,387.28. 
 
You have been asked to pay 20% coinsurance for hospital outpatient services. This item/service falls within the 
Outpatient Surgery and Other Medical 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 coinsurance for hospital outpatient 
services provided on July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99231) provided on July 13, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed cannot be separately paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99231 is not supported in the medical record. Specifically, this service is included in the 
90 day global surgery package for code 35301 which was also billed. 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 (99231) provided on July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two osseous surgeries (D4260 x2), bone replacement 
grafts (codes D4263 and D4264), and two guided tissue regenerations (D4266 x2). 
 
You asked the Plan to pre-approve the osseous surgeries, bone replacement grafts, and guided tissue 
regenerations. You say that these are medically necessary procedures. The Plan denied your request. The Plan 
says these services are not covered under your benefit package. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two 
osseous surgeries (D4260 x2), bone replacement grafts (codes D4263 and D4264), and two guided tissue 
regenerations (D4266 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 09, 2022. 
 
You asked the Plan to pay for an office visit. You say that the enrollee had surgery and was followed for 
continuity of care. 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 February 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S8948 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for procedure code S8948. You say that you decided to try laser therapy as it is non-
invasive prior to having surgery. You say that this treatment reduced your pain but did not eliminate it. You 
also say that you are now seeking surgery. The Plan denied your request. The Plan says the billed code is 
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 code S8948 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S8948 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S8948 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S8948 billed for date of service July 26, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services and emergency department services 
provided on May 13, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that the enrollee was not considered hospice 
status until after the service were rendered. You also say that the service should eb covered. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The hospice 
benefit is applied based on the date of service and is not time specific. Therefore, we decided that the Plan does 
not have to pay for the ambulance services and emergency department services provided on May 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical records. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation - new or established 
patient (D0150). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee had teeth extracted due to 
cancer and therefore would like to return to the previous provider to have a partial made. 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 a 
comprehensive oral evaluation - new or established patient (D0150).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment  includes placement 
tooth #'s 4 and 5 (D6057). 
 
You asked the Plan to pre-approve the custom fabricated abutment  includes placement tooth #'s 4 and 5 
(D6057). You say that you are in pain and need to have the services approved to complete the job. You also say 
that you can't pay out-of-pocket. The Plan denied your request. The Plan says this service is not covered under 
the benefit package. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
custom fabricated abutment  includes placement tooth #'s 4 and 5 (D6057).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extremity study (93971) provided on March 23, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician service. You say that the coding team reviewed the claim and 
advised the diagnosis was payable for this service. The Plan denied your request. The Plan says services 
performed by an out-of-network provider are 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 in this case is not a network provider with the Plan. 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 extremity study (93971) provided on March 23, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (87798) provided on April 5, 2022 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the claim denied for exceeding the Medicare Medically Unlikely Edit (MUE). 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory service have been met. 
Medical records were not provided to verify that the services were supported and correctly billed. Therefore, 
we decided that the Plan does not have to pay for the laboratory service (87798) provided on April 5, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wound care visit provided on June 17, 2022. 
 
You asked the Plan to pay for a wound care visit. You say that this was medically necessary and should be 
covered. 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 wound care visit 
provided on June 17, 2022.