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

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
September 22, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that the cost share is 
wrong 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 $115 
copayment for emergency care. 
 
You have been asked to pay a $115 copayment for the 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 the emergency room 
services provided on September 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic radiology services provided 
on September 14, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic radiology services. You say that the cost share is 
wrong. 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 outpatient diagnostic tests and therapeutic services andsupplies. 
 
You have been asked to pay a $325 copayment for the diagnostic radiology services. This item/service falls 
within the outpatient diagnostic tests and therapeutic services andsupplies 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 diagnostic radiology services provided on September 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a left side knee orthosis provided on September 5, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the records do not indicate that your knee was specifically evaluated by examination or 
with radiologic imaging, or that was concern for knee instability on exam. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not reveal a recent injury or surgery to the knees or objective physical 
examination evidence of knee instability.  
 
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 a left side knee orthosis provided on September 5, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for surgery. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says covered services must be done with contracted providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The Plan has network providers available who are capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage rules that apply.) We found no exception that would require the Plan to pre-approve these items/services. 
Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for surgery.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for dates of service July 15, 2023, to 
August 13, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the claim 
was not billed with the appropriate admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We looked at the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does match the admission date for the NOA as required. Based on this information, we decided that Medicare 
rules for coverage have been met. Therefore, we decided that the Plan has to pay for the home health care billed 
for dates of service July 15, 2023, to August 13, 2023.  
 
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 copayment for the mental health services provided on 
August 31, 2023. 
 
You asked the Plan to waive the copayment for the mental health services. You say that you should not be 
charged for these 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 $35 
copayment for outpatient mental health care. 
 
You have been asked to pay a $35 copayment for the mental health services. This item/service falls within the 
outpatient mental health 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. However, since the allowed amount is less than the standard copayment, you only owe 
$21.91. Therefore, we decided that the Plan does not have to waive the copayment for the mental health 
services provided on August 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tertiary-care orthopedic consultation to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a tertiary-care orthopedic consultation. You say that the requested services 
are a necessity for your care. The Plan denied your request. The Plan says rules for coverage of OON care have 
not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The provider at issue in this case is not a network provider with the Plan. 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 a tertiary-care orthopedic consultation. Our reviewer says that a tertiary-
care orthopedic consultation is not medically reasonable and necessary in this case. Our physician reviewer 
found that you have right leg pain. Your condition can easily be evaluated and treated by an in-plan specialist. 
There is no need for an OON referral. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a tertiary-care orthopedic consultation have not been met.  
 
The Plan has network providers available who are capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) We found no exception that would require the Plan to pre-approve a tertiary-care orthopedic 
consultation. Therefore, we decided that the Plan does not have to pre-approve a tertiary-care orthopedic 
consultation to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on September 
25, 2023. 
 
You asked the Plan to pay for chronic care management services. You say that the enrollee was residing in a 
nursing facility at the time of service and was, therefore, unable to select a network provider. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 chronic care management services provided on September 25, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT scan) of the head or brain and 
soft tissue in the neck billed with code(s) 70450 and 70490 provided on August 23, 2023. 
 
You asked the Plan to pay for the CT scan. You say that the services were billed correctly and should be paid. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 2, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the CT scan have not been met. Therefore, 
we decided that the Plan does not have to pay for the computed tomography (CT scan) of the head or brain and 
soft tissue in the neck billed with code(s) 70450 and 70490 provided on August 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our reviewer 
says that inpatient psychiatric care is not medically reasonable and necessary in this case. Our physician 
reviewer found that based upon review of the records provided, it is not expected that the enrollee will improve 
in a reasonable period of time, as the enrollee is not showing any dangerousness to self or others, auditory or 
visual hallucinations and is without aggressive behaviors while not showing any acute threats of safety. It does 
not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of 
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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 21, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 July 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vision services provided on September 
08, 2023. 
 
You asked the Plan to waive the copayment for the vision services. You say that this is supposed to be $0. 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 vision care. 
 
You have been asked to pay a $40 copayment for the vision services. This item/service falls within the vision 
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. The records show this visit was not for routine services. Therefore, we decided that the Plan does not have to 
waive the copayment for the vision services provided on September 08, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on June 22, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The Plan had network providers available who were capable of providing the services at issue in this appeal. 
(Please note, items and services received in-network are still subject to any other Medicare coverage rules that 
apply.) The Plan did not pre-approve the services at issue. We found no exception that would require the Plan 
to pay for these services. Therefore, we decided that the Plan does not have to pay for the imaging services 
provided on June 22, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27335-AS-59-LT rendered on August 29, 
2023. 
 
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 procedure code 27335-59-LT is considered inclusive to CPT 27447-AS-LT. 
 
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 
documentation does not support CPT 27335: arthrotomy with synovectomy, knee, anterior AND posterior 
including popliteal area as a separate and distinct procedure from CPT 27447: arthroplasty, knee, condyle and 
plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty). The enrollee was being treated for unilateral primary osteoarthritis of the left knee. She underwent a left total knee 
arthroplasty, left computer navigated knee replacement, and left knee synovectomy of anterior and posterior 
compartments on 8/29/23. This 71-year-old female was being treated for unilateral primary osteoarthritis of the 
left knee. She underwent a left total knee arthroplasty, left computer navigated knee replacement, and left knee 
synovectomy of anterior and posterior compartments on 8/29/23. The procedure details cite laminar spreaders 
were used to remove the medial meniscus, lateral meniscus, anterior and posterior cruciate ligaments, and 
osteophytes from the notch and compartments. A titrated synovectomy was performed in the suprapatellar 
pouch extending modestly medial and lateral. Similarly, a titrated synovectomy was performed around the 
patella, patellar tendon, and quadriceps tendon to visualize the patella and minimize potential scarring and 
crepitus. The replacement was continued. However, the synovectomy was performed for optimal fit and 
tracking of implants. Therefore, the documentation does not support CPT 27335 being reported separately. 
 
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 code 27335-AS-59-LT rendered on August 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit provided on September 13, 2023. 
 You asked the Plan to pay for the psychotherapy visit. You say that you are asking for the review of the 
submitted documents. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 psychotherapy visit provided on September 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92604 billed for date of service September 
13, 2023.  
 
You asked the Plan to pay for procedure code 92604. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the billed number of units is not 
supported by the records as both provided and medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 92604 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE.  
 
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 92604. Our reviewer says that the services at 
issue in this case are not supported by the medical records. Our reviewer found that the provided records 
support that the programming was completed on this date, one for each side. However, as analysis of the 
enrollee's hearing is done for both ears at the same time, one unit is more appropriate. The second unit is not 
reasonable or medically necessary in this case.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 92604 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 92604 billed for date of service September 13, 2023.