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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee fully meets IRF criteria and the 
enrollee's needs cannot be safely met by skilled nursing or home health levels of care. The Plan denied your 
request. The Plan says that based on the medical records received, there is no need for an intensive 
rehabilitation program.  
 
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. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
 and benefit from  the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the cold pad billed for dates of service April 18, 2023, to 
May 8, 2023. 
 
You asked the Plan to pay for  the billed services. You say that medical literature shows the efficacy of the 
treatment rendered. The Plan denied your request. The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 We looked at the file, and Medicare rules. A fluid circulating cold pad with pump (E0218) will be denied as not 
reasonable and necessary. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for  the cold pad billed for dates of service 
April 18, 2023, to May 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve D9944. You say that your teeth are chipped because you grind your teeth. 
The Plan denied your request. The Plan says this is not a covered dental 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 an 
occlusal guard (D9944).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic electrocardiogram 
(EKG) provided on September 09, 2022. 
 
You asked the Plan to waive the copayment for an in-network diagnostic electrocardiogram (EKG). You say 
that when you looked up how much an EKG copay would be, it was listed as $0. Now youre getting charged 
more. 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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $100 copayment for an in-network diagnostic electrocardiogram (EKG). This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies 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 record shows you 
received a diagnostic EKG, and you are responsible for the cost sharing amount. However, since the allowed 
amount is less than the standard copayment, you only owe $56.25. Therefore, we decided that the Plan does not 
have to waive the copayment for an in-network diagnostic electrocardiogram (EKG) provided on September 
09, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network x-ray provided on August 
21, 2023. 
 
You asked the Plan to waive the copayment for an in-network x-ray. You say that you had the x-ray done, but it 
made your pain worse, and you ended up in the emergency room the next day. 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 diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $35 copayment for an in-network x-ray. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies 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 x-ray provided on August 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87481, 87640, 
87653, and 87798 for December 7, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services billed with codes 87481, 87640, 87653, and 87798 for 
December 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 03, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with 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 a $325 
copayment for ambulance services. 
 
You have been asked to pay a $325 copayment for 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 waive the copayment for ambulance services 
provided on June 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, and 88360 billed for April 7, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the TC and PC are separately paid only when they are 
furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the professional and technical components were 
furnished in the same payment locality and cannot be paid separately. Therefore, we decided that the Plan does 
not have to pay for procedure codes 88341, 88342, and 88360 billed for April 7, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90791 billed for May 5, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 May 18, 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 these services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 90791 billed for May 5, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service July 30, 2023. 
 
You asked the Plan to pay for code 99285. You say that the medical records support the billing of code 99285. 
The Plan denied your request. The Plan says code 99285 is not supported by the medical records. The enrollee 
was hemodynamically stable, with normal vital signs and unremarkable lab work. There was no sign of 
multisystem dysfunction, a condition that posed an immediate life threat, nor no acute situation of a complex 
nature to support the level of care billed. No specialty consults or extensive decision making were required. 
Therefore, this claim was down-coded to 99284. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. 
 
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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical records. Our reviewer found this enrollee is a 73-year-old patient with a history of 
hyperlipidemia who presented with lightheadedness. A comprehensive history, exam and work up was 
performed. The condition was acute but uncomplicated and documentation did not support that the condition 
was limb/life threatening. The condition also did not require parenteral controlled substances, emergent 
surgery, or hospitalization.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service July 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth provided on July 19, 2023. 
 
You asked the Plan to pay for telehealth. You say that you are requesting reconsideration for 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 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 telehealth provided on 
July 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network eye procedures provided on 
March 21, 2023, to March 28, 2023. 
 
You asked the Plan to waive the copayment for in-network eye procedures. You say that the procedures were 
so minimal that you feel you should not owe these copayments. 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, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $200 copayment for in-network eye procedures. 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. 
The total you owe is $400 ($200 copayment x 2 visits = $400). Therefore, we decided that the Plan does not 
have to waive the copayment for in-network eye procedures provided on March 21, 2023, to March 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM) 
reader device (E2103). 
 
You asked the Plan to pre-approve a Freestyle Libre 3 CGM reader device. You say that the enrollee is diabetic 
and needs the CGM. The Plan denied your request. The Plan says the enrollee does not meet criteria 
requirements for the CGM. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We looked at the file and Medicare rules. The Freestyle Libre 3 is now a covered device, as it has been 
assigned the covered code of E2103 as of June 15, 2023. Based on this information, we decided that Medicare 
rules for coverage of a Freestyle Libre 3 CGM reader device have been met. Specifically, the enrollee is not 
treated with insulin and does not have a history of more than one level 2 or 3 hypoglycemic events. Therefore, 
we decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM) 
reader device (E2103).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the growth removal procedure provided on 
May 05, 2023, to May 16, 2023. 
 
You asked the Plan to waive the copayment for the growth removal procedure. You say that you 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 a $325 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $325 copayment for the growth removal procedure. This item/service falls 
within the outpatient surgery, including services provided at hospital outpatient facilities 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 growth removal procedure provided on May 05, 2023, to 
May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit provided by an out-of-
network provider on July 10, 2023. 
 
You asked the Plan to waive the deductible for the office visit. You say that you were not aware that the 
provider was not 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. Your 
contract with the Plan says that there is a $1,500 deductible which applies to out-of-network office visits. 
 
You have been asked to pay a $130.73 deductible for the office visit. The item or service you asked the Plan to 
waive the deductible for was provided by an out-of-network provider. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $1,500 deductible which applies to out-of-network office visits. 
This cost sharing is a contractual obligation that had not been met at the time the office visit was received on 
July 10, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the office visit 
provided by an out-of-network provider on July 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for foot x-rays provided on June 07, 2023. 
 
You asked the Plan to waive the copayment for foot x-rays. You say that there should be no separate charge for 
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 $15 
copayment for each in-network Medicare-covered standard x-ray service. 
 
You have been asked to pay a $15 copayment for foot x-rays. This item/service falls within the each in-network 
Medicare-covered standard x-ray service 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 foot x-rays provided on June 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on September 16, 2022. 
 
You asked the Plan to pay for the therapy services. 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 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 therapy services 
provided on September 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the multi-layer compression system, the low frequency 
ultrasound, and the office visit provided on July 06, 2023. 
 
You asked the Plan to pay for the multi-layer compression system, the low frequency ultrasound, and the office 
visit. You say that you say that the provider is 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 multi-layer 
compression system, the low frequency ultrasound, and the office visit provided on July 06, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth psychotherapy provided on August 4, 2023. 
 
You asked the Plan to pay for telehealth psychotherapy. You say that the services were medically necessary. 
The Plan denied your request. The Plan says telehealth must be provided by a network provider who offers the 
service by telehealth. 
 
The Plan contract says the Plan covers certain telehealth services. The enrollee has the option of getting these 
services through an in-person visit or by telehealth. The enrollee must use a network provider who offers the 
service by telehealth. 
 
We looked at the file and the Plans rules. The file shows the provider is not a network provider. Based on this 
information, we decided that the Plans rules for coverage of telehealth psychotherapy have not been met. 
Therefore, we decided that the Plan does not have to pay for telehealth psychotherapy provided on  
August 4, 2023.