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 an IRF admission is necessary for the enrollee's 
recovery and safety. The Plan denied your request. The Plan says the requested IRF services do not meet the 
requirements for approval. 
 
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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 
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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on March 22, 2022. 
 
You asked the Plan to pay for a facility visit. You say that this was medically necessary and should be covered. 
The facility did not get the proper documentation. 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 facility visit provided 
on March 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on August 10, 2022. 
 
You asked the Plan to pay for radiology services provided.. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 93042-51 is a column II code to column I code 12011; however, 
93042-51 was billed with a modifier.  
 
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 radiology services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the enrollee is a 78-year-old male that 
received services on August 10, 2022.  Provider reported, Current Procedural Terminology (CPT) 93042 
Rhythm electrocardiogram (ECG) interpretation and report only in addition to simple repair procedure for 
service provided.  Documentation submitted was reviewed and does not meet criteria.  An edit exists between 
column I code 93042 and column II code 12011. Medicare allows for a modifier to bypass the edit, and in this 
case an appropriate modifier should be appended 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiology services provided. have not been met. Therefore, we decided that the 
Plan does not have to pay for radiological services provided on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for periodic oral evaluation - established patient (D0120), bitewings - four 
radiographic images (D0274), prophylaxis - adult (D1110) and unspecified preventive procedure, by report 
(D1999) provided on June 8, 2022. 
 
You asked the Plan to pay for dental services. You say that the Plan has always paid for your dental checkups 
with this provider, so you do not understand why they are not covering this visit. The Plan denied your request. 
The Plan says that we have paid the annual limit allowed by your dental plan for this benefit year. 
 
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 send us any documentation showing that you have 
met your $1,000 annual maximum benefit. The Plan has always covered your dental checkups. You do not 
understand why these services were not covered. Without documentation showing you have met your $1,000 
annual maximum benefit we cannot determine if the Plans decision to not pay for services is correct. Therefore, 
we decided that the Plan has to pay for periodic oral evaluation - established patient (D0120), bitewings - four 
radiographic images (D0274), prophylaxis - adult (D1110) and unspecified preventive procedure, by report 
(D1999) provided on June 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network office visit provided on 
September 15, 2022. 
 
You asked the Plan to waive the coinsurance for an out-of-network office visit. You say that you disagree with 
the coinsurance. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 30% coinsurance for out-of-network physician/practitioner services/provider and professional 
services.  
 
The enrollee has been asked to pay a 30% coinsurance for an out-of-network office visit. The total allowed 
amount for the office visit is $322.07 ($322.07 x 20% = $96.62). However, you are being asked to pay $96.61 
which is less than the required amount. This item/service falls within the out-of-network physician/practitioner 
services/provider and professional services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for an out-of-network office visit provided on September 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs can be safely met at 
an LTACH level of care. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee's needs can be met at an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a home ventilator provided on October 1, 
2022, and November 1, 2022. 
 
You asked the Plan to waive the coinsurance for a ventilator. You say that you cannot afford the monthly 
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 a 20% 
coinsurance for DME purchased from a non-preferred provider. 
 
You have been asked to pay a $233.56 coinsurance for each month with a ventilator ($1167.80 allowed amount 
x 20% coinsurance = $233.56). You have been asked to pay a total of $467.12 coinsurance for two months of 
service ($233.56 coinsurance x 2 months = $467.12 coinsurance). This item/service falls within the durable 
medical equipment (DME) purchased from a non-preferred provider 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 a home ventilator provided on October 1, 2022, and November 1, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the ophthalmic diagnostic imaging 
provided on October 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and the ophthalmic diagnostic imaging. You say that the services 
were medically necessary, the care was performed in good faith, and Medicare guidelines say plans are 
generally required to reimburse non-contracting providers at least the original Medicare rate for Medicare-
covered services. The Plan denied your request. The Plan says there was no valid authorization for the services. 
 
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 did not pre-approve the 
office visit and the ophthalmic diagnostic imaging. We found no exception that would require the Plan to pay 
for the office visit and the ophthalmic diagnostic imaging. Therefore, we decided that the Plan does not have to 
pay for the office visit and the ophthalmic diagnostic imaging provided on October 19, 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 outpatient hospital services provided on August 25, 2022. 
 
You asked the Plan to pay for the outpatient hospital services. 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 find that CPT code 64624 is not supported in the medical record. This code has a bilateral surgery indicator 
of 1. This means the code should be reported with 1 unit of service and modifier 50 (bilateral modifier) or an 
appropriate anatomical modifier (right or left) to be considered for payment. Based on this information, we 
decided that Medicare rules for coverage of code 64624 have not been met. The file does show that code 64624 
was billed with modifier 74; however, no medical records were provided for review to determine if this 
modifier is appropriate for billing based on Medicare criteria. Therefore, we decided that the Plan does not 
have to pay for the outpatient hospital services provided on August 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ambulance services provided on July 
12, 2022. 
 
You asked the Plan to reduce the copayment for the ambulance services. You say that you were only in the 
ambulance for five minutes. 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 $260 
copayment for each out-of-network Medicare-covered one-way ambulance trip.  
 
You have been asked to pay a $260 copayment for the ambulance services. 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 reduce the copayment for the ambulance 
services provided on July 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
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 clinical documentation shows that the enrollee has active medical 
comorbidities however, no complex functional impairments are specified. Thus, the complexity of the 
enrollee's documented nursing, medical and rehabilitation needs would not be expected to require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Additionally, therapy notes 
do not show that the enrollee would tolerate 15 hours of therapy per week. 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the cardiac ablation procedure performed 
by an out-of-network provider on May 25, 2022. 
 
You asked the Plan to waive the cost sharing for the cardiac ablation procedure. You say that you were told that 
this provider was in-network. 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% 
coinsurance, after the $500 deductible, for each out-of-network Medicare-covered outpatient surgery at an 
outpatient hospital facility. 
 
 
 
 You have been asked to pay a cost share of $4290.81 for the cardiac ablation procedure ($21,454.04 allowed 
amount x .20 = $4290.81 rounded up). This item/service falls within the outpatient surgery, including 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 cost sharing for the cardiac ablation procedure performed by an out-of-network 
provider on May 25, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services provided on July 20, 2022. 
 
You asked the Plan to pay for the ambulance 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 ambulance services based on Medicare criteria. Therefore, we decided that the Plan has to pay 
for the ambulance services provided on July 20, 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 waive the cost share for annual wellness visit provided on October 
27, 2022. 
 
You asked the Plan to waive the cost share for annual wellness visit. You say that you disagree with the cost 
share. 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. Your 
contract with the Plan says that there is a $800 deductible which applies to annual wellness visit.  
 
The item or service you asked the Plan to waive the cost share for falls within the annual wellness visit benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $800 
deductible which applies to annual wellness visit. You are being asked to pay $132.18 towards your $800 
deductible. This cost sharing is a contractual obligation that had not been met at the time annual wellness visit 
was received on October 27, 2022. Therefore, we decided that the Plan does not have to waive the cost share 
for annual wellness visit provided on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on December 3, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that the enrollee was in a nursing home setting and could 
not choose a network provider. The Plan denied your request. The Plan says no authorization was 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
eye exam. We found no exception that would require the Plan to pay for the eye exam. Therefore, we decided 
that the Plan does not have to pay for the eye exam provided on December 3, 2021, by an out-of-network 
(OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for a single-photon emission computerized 
tomography (SPECT) and technetium provided on October 27, 2022. 
 
You asked the Plan to waive the cost sharing for the SPECT scan and technetium. You say that you were told 
by the provider's office this would be a covered 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 $185 
copayment for Medicare-covered radiological diagnostic services, which includes a SPECT scan.  
 
You have been asked to pay a $185 copayment for the SPECT scan. You have also been asked to pay $180.23, 
which is 20% coinsurance of the allowed amount for the medical supplies ($901.16 allowed amount x 20% coinsurance = $180.23). You have been asked to pay a total of $365.23 ($185 copayment + $180.23 
coinsurance = 365.23). These items/services fall within the 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 cost sharing for a single-photon emission 
computerized tomography (SPECT) and technetium provided on October 27, 2022.