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

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 5, 2022, 
through February 7, 2022. 
 
You asked the Plan to pay for these services. You say that the acute inpatient hospital care provided was 
medically necessary. The Plan denied your request. The Plan says that the acute inpatient hospital care 
provided was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that you presented to the emergency department (ED) on February 5, 2022 with palpitations. You were 
found to have narrow complex tachycardia. You were then admitted to medicine with a cardiology 
consultation. Your diagnoses were palpitations, supraventricular tachycardia, and paroxysmal atrial fibrillation. 
You were then discharged the following day. The review has determined that the record showed that at the time 
of the inpatient admission, the admitting physician reasonably expected that your necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from February 5, 2022, through February 7, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99308), provided on August 9, 
2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the service should be covered. The Plan 
denied your request. The Plan says the member was enrolled in hospice on this date of service. 
 
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. Therefore, 
we decided that the Plan does not have to pay for the nursing facility care (99308), provided on August 9, 2022.
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 the IRF admission is necessary for the enrollee as 
she is a high risk for falls, injury, and re-admission to acute care. You also say that at this time, the services 
required by the enrollee cannot be safely met with home health services or at a skilled nursing facility. The 
Plan denied your request. The Plan says the enrollee does not meet all the requirements for an IRF admission. 
 
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 it has been evident in clinical practice and evidence-based data that an IRF admission is not medically necessary for rehabilitation following an uncomplicated total knee replacement as 
was performed for this enrollee. She does not require a IRF admission, frequent physiatry oversight or 
rehabilitation nursing. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941 x 3) 
provided from August 4, 2022, through September 29, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided do not meet criteria for 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 pay for these services. Our reviewer says that the 
services provided were not medically necessary. Our physician reviewer found that in this case, the record 
indicates that you have a spinal subluxation. The record provided indicates that you are to return "as needed." 
The records provided are insufficient to establish whether these visits were to treat an acute condition or were 
for maintenance therapy. The elements of the coverage criteria are not satisfied.   
 
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 pay for the chiropractic manipulative treatments (98941 x 3) provided from August 4, 2022, through 
September 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental surgical procedure for isolation of tooth with 
rubber dam (D3910). 
 
You asked the Plan to pre-approve a dental surgical procedure. You say that this is medically necessary. The 
Plan denied your request. The Plan says the requested dental 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 pre-approve a 
dental surgical procedure for isolation of tooth with rubber dam (D3910).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like the Plan to approve these 
orthotics. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0860) and accessories. 
 
You asked the Plan to pre-approve the Group 3 power wheelchair and accessories. You say that this is the 
wheelchair your doctor ordered. The Plan denied your request. The Plan says that you do not have a qualifying 
condition for a Group 3 power wheelchair. 
 
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 file does 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 (K0860) and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 12, 
2021, through April 18, 2021, at the Diagnosis Related Group (DRG) 853 originally billed. 
 You asked the Plan to pay for the acute inpatient hospital care billed at DRG 853. You say that you are 
requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the 
clinical evidence provided does not support the diagnosis code indicated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.02 as defined by sepsis due to 
Methicillin resistant Staphylococcus aureus. 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 pay for the 
inpatient hospital services at the DRG originally billed. Our reviewer says that the acute inpatient hospital care 
provided was not billed correctly. Our physician reviewer found that in this case, there was no evidence of a 
life-threatening organ dysfunction due to dysregulated host response to an infection, persistent hemodynamic 
instability, or cognitive impairment that would be consistent with multi-system involvement due to sepsis. The 
review has determined that the documentation provided did not support diagnosis code A41.02 indicated. The 
record supports DRG 659. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the acute inpatient hospital care provided from April 12, 2021, through April 18, 2021, at the Diagnosis 
Related Group (DRG) 853 originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nasal endoscopy provided on February 
24, 2022. 
 
You asked the Plan to waive the copayment for the nasal endoscopy. You say that the nasal endoscopy was not 
performed. 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 $50 
copayment for Medicare-covered outpatient diagnostic tests.  
 
The medical records show that a nasal endoscopy was provided on February 24, 2022. You have been asked to 
pay a $50 copayment for the nasal endoscopy. This item/service falls within outpatient diagnostic tests and 
therapeutic 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 a nasal endoscopy 
provided on February 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 70490, 71250, 73200, 73700, 74176 
rendered on September 16, 2022. 
 
 
You asked the Plan to pay for the services. You say that this should be reconsidered. The Plan denied your 
request. The Plan says the review determined that the billed services were not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 pay for the services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
record states that these imaging services are included in the position emission tomography (PET) scan reported 
with CPT 78813. No distinct and separate diagnostic imaging was performed that would support the use of 
modifier -59. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 70490, 71250, 73200, 73700, 74176 rendered on September 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital analysis of electroencephalogram (EEG) (eg, for 
epileptic spike analysis) rendered on June 5, 2022. 
 
You asked the Plan to pay for the services. You say that you attached medical records for review. The Plan 
denied your request. The Plan says Current Procedural Terminology (CPT) code 95957 (1 unit) remains 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 95957 is "Digital analysis of electroencephalogram 
(EEG) (eg, for epileptic spike analysis)." 
 
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 enrollee under a routine 
electroencephalogram (EEG). There is no evidence that digital analysis of the data was performed, beyond 
running a spike and wave detection algorithm.  
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 digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) rendered on 
June 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on June 28, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you should not have a copayment 
for the services. 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 $40 
copayment for out-of-network primary care doctor visits. 
 
You have been asked to pay a $40 copayment for the office visit. This item/service falls within the out-of-
network primary care doctor visits 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 
the office visit provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) and therapeutic injection (96374), 
provided on January 6, 2022, through September 9, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services should be covered. The Plan 
denied your request. The Plan says you received these services from a provider who has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visit (99215) and therapeutic injection (96374), provided on January 6, 2022, through September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on October 12, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the copayment 
being billed. 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 $20.00 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $20.00 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 office visit provided on October 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services: medical examination and 
evaluation with initiation of diagnostic and treatment program; comprehensive, new patient (92004) provided 
on October 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that this service should be covered. The Plan denied your 
request. The Plan says this service is not covered when provided OON without prior authorization. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by the Plan's vision vendor or Plan network providers. 
 
We looked at the file and the Plan's rules. The requested service was provided OON without prior 
authorization. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not 
been met. Therefore, we decided that the Plan does not have to pay for the ophthalmological services: medical 
examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient 
(92004) provided on October 3, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic labratory services provided on March 15, 2022. 
 
You asked the Plan to pay for genetic labratory services. 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 genetic labratory 
services provided on March 15, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on June 06, 2022, to 
September 16, 2022. 
 
You asked the Plan to pay for the mental health services. You say that you were informed that all of your 
current providers were in-network. 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 the mental health 
services provided on June 06, 2022, to September 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on November 19, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that you were never informed of a copay for 
an MRI. 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 $180 
copayment for advanced imaging services provided in an office or freestanding radiology facility.  
 
You have been asked to pay a $180 copayment for an MRI. This item/service falls within the advanced 
imaging services provided in an office or freestanding radiology facility benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an MRI provided on November 19, 2022.