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

 
We decided that the Plan does not have to pre-approve Monoferric. 
 
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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 the enrollee has iron deficiency anemia 
and has failed treatment with oral iron replacement. She has not tried and failed the Plan's required drugs, Infed 
and Venofer. The records do not support that the required drugs would be contraindicated or less effective; 
therefore, Monoferric is not reasonable or 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 Monoferric.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) provided to the 
enrollee on June 15, 2022. 
 
 
You asked the Plan to pay for the services. You say that this should be paid for. 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 code 99223 is "Initial hospital care, per day, 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. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 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 evaluation and management 
code billed requires these 3 key components: a comprehensive history, a comprehensive examination; and 
medical decision making of high complexity. However, the medical records submitted don't support a 
comprehensive history and medical decision making of high complexity. 
 
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 initial hospital care (procedure code 99223) provided to the enrollee on June 15, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit coded 99284 provided on 
August 3, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that you disagree with the Plan's 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 code 99284 is not supported in the medical record. Specifically, this code was billed on the 
same date of service as surgery code G0168 (wound closure utilizing tissue adhesive(s) only). Code 99284 was 
not billed with an appropriate modifier; therefore, this code is considered included in the global surgery 
package for code G0168.  Based on this information, we decided that Medicare rules for coverage of the emergency department visit have 
not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit 
coded 99284 provided on August 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Go-Go Sport 4-wheel scooter. 
 
You asked the Plan to pre-approve a Go-Go Sport 4-wheel scooter. You say that the item is necessary. The 
Plan denied your request. The Plan says the item is being requested for travel purposes. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a Go-Go Sport 4-wheel scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) and respiratory polymerase 
chain reaction (PCR) panels (87481, 87500, 87511, 87529, 87641, 87651, 87653, 87661) provided on 
September 7, 2022. 
 
You asked the Plan to pay for the UTI and respiratory PCR panels. You say that this testing should be covered. 
The Plan denied your request. The Plan says the panels are denied because they were not billed under a single 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The services at issue should be billed with single panel codes. Based 
on this information, we decided that Medicare rules for coverage of the UTI and respiratory PCR panels have not been met. Therefore, we decided that the Plan does not have to pay for the urinary tract infection (UTI) and 
respiratory polymerase chain reaction (PCR) panels (87481, 87500, 87511, 87529, 87641, 87651, 87653, 
87661) provided on September 7, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 72170 and 73562 provided on September 4, 2022. 
 
You asked the Plan to pay for codes 72170 and 73562. You say that you disagree with the Plan's 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 72170 and 73562 are not supported in the medical record. Specifically, code 99284 
was billed on the same claim, with the same date of service, with a revenue code of 450. This gives code 99284 
a status indicator of "V". Codes 72170 and 73562 have a status indicator of Q1. This means codes 72170 and 
73562 are not separately payable. Based on this information, we decided that Medicare rules for coverage of 
codes 72170 and 73562 have not been met. Therefore, we decided that the Plan does not have to pay for codes 
72170 and 73562 provided on September 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on 
September 20, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copaymet. 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/outpatient surgery and/or services at an ambulatory surgical center. 
 
You have been asked to pay a $200 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/outpatient surgery and/or services at an ambulatory surgical center benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an outpatient surgery provided on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on November 28, 
2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you do not agree with the copayment 
assessed. 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 $25 
copayment for physician/practitioner services, including doctors office visitp. 
 
You have been asked to pay a $25 copayment for office visit. This item/service falls within the 
physician/practitioner services, including doctors office visitp 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 office visit provided on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on December 14, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 pay for the dental 
services on December 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for inpatient hospital services provided from 
September 25, 2022, to October 6, 2022, and durable medical equipment (DME) provided from October 6, 
2022, and November 11, 2022. 
 
You asked the Plan to waive the cost share for inpatient hospital services and DME. You say that these services 
were the result of a fall at the hospital. 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 per day for days 1-5 of Medicare-covered inpatient hospital stays. Your contract also says that you 
must pay 20% coinsurance for DME.  
 
 You have been asked to pay a total of $1,000, which is a $200 copayment for days 1-5 of an inpatient hospital 
stay provided from September 25, 2022, to October 6, 2022 ($200 copayment x 5 days = $1,000). This 
item/service falls within the inpatient hospital care benefit category.  
 
You have been asked to pay 20% coinsurance the durable medical equipment provided from October 6, 2022, 
to November 11, 2022. These items/services fall within the durable medical equipment benefit category. 
 
Date of Service Code Allowed Amount 20% Coinsurance 
October 6, 2022 E0185 $222.45 $44.49 
October 6, 2022 K0001 $34.14 $6.83 
October 6, 2022 E0973 $135.31 $27.06 
October 6, 2022 E0971 $73.62 $14.72 
October 6, 2022 E0163 $74.02 $14.80 
October 11, 2022 E0260 $86.97 $17.39 
November 6, 2022 K0001 $34.14 $6.83 
November 11, 2022 E0260 $86.97 $17.39 
 
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 cost share for inpatient hospital services provided from September 25, 
2022, to October 6, 2022, and durable medical equipment (DME) provided from October 6, 2022, and 
November 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services and electrocardiogram (EKG) provided on 
September 12, 2022. 
 
You asked the Plan to pay for radiology services and electrocardiogram (EKG). You say that you are appealing 
the claim payment denial. 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 radiology services and 
electrocardiogram (EKG) provided on September 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound provided on October 28, 2022. 
 
You asked the Plan to pay for ultrasound. You say that you are appealing the claim payment denial. 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 ultrasound provided on 
October 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 28296 provided on September 23, 2022. 
 
You asked the Plan to pay for procedure code 28296. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Medicare guidelines state that modifiers -LT and -RT are to be used 
to identify procedures, which can be performed on paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and 
ovaries. Modifiers -LT and -RT should be used whenever a procedure is performed on only one side. Hospitals 
use the appropriate -LT or -RT modifier to identify which of the paired organs was operated upon. In this case, the file shows that the claim was not billed with an appropriate modifier. Therefore, we decided that the Plan 
does not have to pay for procedure code 28296 provided on September 23, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services provided on September 8, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for the anesthesia services based on Medicare criteria. Therefore, we decided that the Plan has to pay 
for the anesthesia services provided on September 8, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network ambulance ride provided on 
August 31, 2022. 
 
You asked the Plan to waive the copayment for an in-network ambulance ride. You say that you had to be 
taken from one hospital to another, as the first one could not help you. You did not request this service. 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 $325 
copayment for ambulance services. 
 
You have been asked to pay a $325 copayment for an in-network ambulance ride. 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 an in-
network ambulance ride provided on August 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
September 4, 2022, to September 11, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you are retired and 
cannot afford 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 $325 per 
day for days 1-5 of each Medicare-covered hospital stay. The contract also says that enrollees must pay a $0 
copayment per day for days 6-90. 
 
You have been asked to pay a total of $1,625, which is a $325 copayment for days 1-5 of an inpatient hospital 
stay ($325 copayment x 5 days = $1,625). You are not being charged a cost sharing amount for days six and 
seven of your inpatient hospital stay. This item/service falls within the inpatient hospital care benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an inpatient hospital stay provided from September 4, 2022, 
to September 11, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on September 21, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration. 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 skilled nursing facility 
care provided on September 21, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on May 
21, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you disagree with the 
copaymet. 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 May 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 14, 2022. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. 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 office visit provided on 
September 14, 2022.