Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on September 01, 2022, to 
September 30, 2022. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
provided on September 01, 2022, to September 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for noninvasive estimated coronary fractional flow reserve 
(FFR) provided on July 30, 2022. 
 
You asked the Plan to pay for noninvasive estimated coronary fractional flow reserve (FFR). You say that this 
service is supported in the records. 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 noninvasive estimated 
coronary fractional flow reserve (FFR) provided on July 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colorectal cancer screening provided on November 11, 2022. 
 
You asked the Plan to pay for colorectal cancer screening. You say that you believe that this service 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 colorectal cancer 
screening provided on November 11, 2022.
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 the requested items are medically necessary. 
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.   
 
The 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 04, 2021. 
 
You asked the Plan to pay for an office visit. You say that the services 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 an office visit provided 
on October 04, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on February 09, 
2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you did not receive any additional 
medical services at this visit. 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 $10 
copayment for each covered visit or consultation in an outpatient location with your primary care physician or 
other primary care provider.  
You have been asked to pay a $10 copayment for an office visit. This item/service falls within the each covered 
visit or consultation in an outpatient location with your primary care physician or other primary care 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 copayment for an office visit provided on 
February 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on January 30, 
2023. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that this did not happen in an 
observation room, and you believe there is a coding error. 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 $250 
copayment for outpatient surgery provided at an outpatient hospital. 
 
You have been asked to pay a $250 copayment for the arthrocentesis. This item/service falls within the 
outpatient surgery provided at an outpatient hospital 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. According to Medicare an arthrocentesis (code 20610) is 
considered outpatient surgery. Therefore, we decided that the Plan does not have to waive the copayment for 
the arthrocentesis provided on January 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that you do not have a qualifying diagnosis 
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 and accessories.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on July 21, 
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 provider is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers services in freestanding emergency 
departments only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The provider is a freestanding ER not affiliated with a hospital. These 
services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the 
emergency room (ER) services rendered on July 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0100). 
 
 
 You asked the Plan to pre-approve the additional non-emergency transportation trips. You say that you 
disagree with the denial. The Plan denied your request. The Plan says you have used or scheduled 100 one-way 
trips. Your 100 trips may include some trips that you have already scheduled but have not yet been used. Your 
101st trip is not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0100).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798, 87653, 87640, 87481) provided on 
November 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87798, 87653, 87640, 87481) provided on 
November 16, 2022.
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 you are requesting an expedited 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 that the enrollee is medically stable and does not require physician supervision three 
times a week in the IRF. There are no acute rehab or nursing needs identified or documented. At the current 
functional level, the enrollee does not need specialized and intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF. The complexity of the 
enrollee's nursing, rehab, and medical, needs (combined complexity) does not require an acute hospital 
inpatient rehab stay with an interdisciplinary approach to rehabilitative care. Rehab needs can be provided in a 
lower intensity and alternate setting such as in a skilled nursing facility. 
 
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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 88341 & 88342 billed for date of service 
July 12, 2022.  
 
You asked the Plan to pay for procedure codes 88341 & 88342. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
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 88341 is 13. 26 Units of this code were billed. The MUE for CPT 88342 is 
4. 13 units of this code were billed. The MAI value for this code is 3. You did not provide all the required 
evidence showing that the excess units were actually provided, were correctly coded, and were medically 
necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 88341 & 
88342 have not been met.  Therefore, we decided that the Plan does not have to pay for procedure codes 88341 
& 88342 billed for date of service July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy (D3330) for tooth #14 provided 
on January 30, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you were never told the provider was an 
out-of-network provider and you would like the dental service paid for. The Plan denied your request. The Plan 
says your maximum dental benefit for the year has already been exhausted. 
 
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, certain limitations apply. The record 
shows that the Plan paid $2,000 for dental services on January 30, 2023; therefore, your maximum dental 
benefit for the year of 2022 was exhausted on the date of service of January 30, 2023. Therefore, we decided 
that the Plan does not have to pay more for the endodontic therapy (D3330) for tooth #14 provided on January 
30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of root canal (D3331) and a consultation 
(D9310) provided on December 7, 2022. 
 
You asked the Plan to pay for the dental service. You say that the provider used all of your benefit coverage 
and you did not get your teeth cleaned. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because the treatment of root canal and the consultation are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
treatment of root canal (D3331) and a consultation (D9310) provided on December 7, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve physical therapy services. You say that you do not want to go into any of 
the other in-network providers because this practice is smaller and easier to navigate. The Plan denied your 
request. The Plan says there are many other in-network providers who are close to your residence, whom you 
need to see first. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. 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 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 73562-RT and 73562-59-LT billed for date 
of service July 15, 2022. 
 
You asked the Plan to pay for the services. You say that these services were reported appropriately. The Plan 
denied your request. The Plan says these services are not supported in the medical record. 
 
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 73562 is "Radiological examination, knee 3 views." 
 
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 in this case, three views for this x-ray cannot be verified by the records. 
 
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 procedure codes 73562-RT and 73562-59-LT billed for date of service July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), the intraoral radiographic 
images (D0220 and D0230), a cleaning (D1110), an amalgam (D2161), and resin-based composites (D2335) 
for tooth #4, #8, and #27 provided by an out-of-network provider on March 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were never told that you did not have out-
of-network benefits and you would like the claim to be approved. The Plan denied your request. The Plan says 
the dental services were received from an out-of-network provider and are not covered by your supplemental 
benefits.  
 
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. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), the intraoral radiographic images (D0220 and D0230), a cleaning 
(D1110), an amalgam (D2161), and resin-based composites (D2335) for tooth #4, #8, and #27 provided by an 
out-of-network provider on March 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neck surgery. 
 
You asked the Plan to pre-approve neck surgery. You say that the enrollee has difficulty swallowing. The Plan 
denied your request. The Plan says this surgery is not medically necessary. 
 
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 pre-approve neck surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found there is no note from a surgeon and no swallowing study in the medical record. More clinical 
information is needed to justify the osteophyte resection surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neck surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve neck surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is not stable for a sub-acute 
rehab.  The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care 
and is currently unstable for transfer to an LTACH.  
 
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 the enrollee appears to be currently unstable and worsening and requires additional 
acute care services that can safely be completed at the current facility until more appropriate and stable for 
transfer. The enrollee does not require services at the LTACH that are not already available at the current 
facility. Completion of treatment at the current facility is recommended.  
 
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 long term acute care hospital (LTACH) services.