Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services and an office visit provided from 
December 1, 2022, to December 26, 2022. 
 
You asked the Plan to pay for the psychotherapy services and an office visit. The Plan denied your request. The 
Plan says the Plan requires utilization of network providers when possible and available and requires 
authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an 
emergent situation that has been documented.   
 
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 
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 psychotherapy services and an office visit provided from 
December 1, 2022, to December 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 rendered on 
March 6, 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 the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered. 
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin 
therapy. 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 96365, 96366, and 96521 
rendered on March 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation provided on August 19, 2022. 
 
You asked the Plan to pay for electrical stimulation. You say that you are appealing the denial. The Plan denied 
your request. The Plan says that electrostimulation is considered investigational and is not eligible for coverage 
for the treatment of neuropathies or peripheral neuropathies. 
 
The Plan must follow Medicare rules. Medicare rules say that use of electrostimulation procedures for 
neuropathies is considered investigational and are not eligible for coverage.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of electrical stimulation have not been met. Therefore, we decided that the Plan does not have to pay 
for electrical stimulation provided on August 19, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Emergency room services provided on February 17, 2023 
 
You asked the Plan to pay for the Emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for Emergency room services provided on February 17, 2023
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S5000 billed for date of service March 17, 
2022. 
 
You asked the Plan to pay for procedure code S5000. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S5000 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S5000 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S5000 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S5000 billed for date of service March 17, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on August 20, 2022, to August 26, 
2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says that diagnosis code A41.9 is not 
supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that diagnosis code A41.9 is supported by the records. Our physician reviewer found the enrollee presented 
with fever, tachycardia, tachypnea, and altered mental status. She had systemic inflammatory response 
syndrome with a confirmed urinary tract infection, thus meeting the criteria for diagnosis code A41.9. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on August 20, 2022, to August 26, 2022, at the Diagnosis Related Group (DRG) 
originally billed.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 14, 2023, and 
February 16, 2023. 
 
You asked the Plan to pay for home health services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. The Plan requested a waiver of liability (WOL) to include both dates 
of service but did not receive one. The WOL that was included in the documents has only February 14, 2023, 
as the date of service. Based on this information, we decided that there is insufficient information in the record 
to determine if Medicare rules for coverage of home health services have been met. Therefore, we decided that 
the Plan does not have to pay for home health services provided on February 14, 2023, and February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Chimeric Antigen Receptor (CAR) T-cell therapy. 
 
You asked the Plan to pre-approve the services. You say that the enrollee has cancer. The Plan denied your 
request. The Plan says this does not meet the criteria. 
 
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 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 provided medical records do not document in the enrollee's lymphoma is relapsed or refractory, 
as is required for this treatment. A positron emission tomography/computed tomography (PET/CT) scan 
showed "no disease recurrence."  
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 pre-approve Chimeric Antigen Receptor (CAR) T-cell therapy.
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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet criteria. 
 
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 enrollee was admitted for lumbar and sacral fractures after a fall. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical 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 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: 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 it is unsafe for the enrollee to go home.  The Plan 
denied your request. The Plan says the enrollee's records do not show the need for an intensive team for care. 
Services needed may be provided safely in a lower level of care. 
 
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 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. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from March 
9, 2023, to March 31, 2023. 
 
You asked the Plan to pay for the SNF services. You say that the previous SNF discharged your father, and he 
was not back to his physical capabilities prior to his injuries. As a result, this claim should be paid. The Plan 
denied your request. The Plan says it agrees that these SNF services were medically necessary, but the SNF 
billed these services incorrectly.  The Plan says that the SNF billed an incorrect number of service units on the 
claim.  The Plan has requested a corrected claim from the SNF three times, but it has not been submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the service units billed must contain the number 
of covered days for each HIPPS rate code.  
 
In this case, the bill indicates that the service in dispute cover 22 days.  However, the SNF billed with a total of 
23 service units.  They should have billed with 22 service units.  That is why a corrected claim is needed.  The 
Plan cannot be obligated to pay this claim until the SNF bills with the correct number of service units. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for 
skilled nursing facility (SNF) services provided from March 9, 2023, to March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for otolaryngology care provided in the French Republic on February 2, 
2023. 
 You asked the Plan to pay for otolaryngology care. You say that you experienced an incident of extreme 
vertigo which you considered to be an emergency. The Plan denied your request. The Plan says that this was 
not emergency care. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States are only covered in limited, specified circumstances. The rules say that an emergency exists 
based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered 
emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would 
reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. 
The Plan has a worldwide coverage benefit that goes beyond Medicares rules. The Plan covers worldwide 
emergency and urgent care services. 
 
We looked at the file, the Plans rules, and Medicare rules. We decided that this case does meet prudent 
layperson criteria for emergency care. You experienced a sudden incident of extreme vertigo while in France, 
which caused you to fall and be unable to stand or walk without assistance. You sought care from a doctor in 
France to stabilize your condition. The effects of vertigo can represent serious risks to life, limb, or function of 
a limb. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical care to seriously jeopardize their health in this case. Based on this information, we decided 
that Medicare rules for coverage of otolaryngology care have been met. Therefore, we decided that the Plan has 
to pay for otolaryngology care provided in the French Republic on February 2, 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 radiation therapy services provided 
from October 4, 2022, to October 31, 2022. 
 
You asked the Plan to waive the copayment for the radiation therapy services. You say that you were told that 
the charges would be waived. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each Medicare-covered radiation therapy service. 
 
 You have been asked to pay a $769.57 copayment for the radiation therapy services because your out-of-pocket 
maximum was met partway through the processing of the claim. These items/services fall 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 the radiation therapy services provided from October 4, 2022, to October 31, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to approve in-network coverage for a consultation with an out-of-network (OON) 
orthopedic surgeon.  
 
You asked the Plan to approve in-network coverage for the OON orthopedics consultation . You say that the 
enrollee needs consultation for surgery due to bone metastases which are causing pain and disability. The 
provider he has been seeing is too far from the enrollee and a closer provider is needed to allow for care and 
treatment planning. The Plan denied your request. The Plan says that the code used for this service is invalid 
for Medicare purposes. As such, the requested consultation was denied.  
 
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 did not provide a valid rationale for a request for 
authorization of service. The rationale for which this request was denied was due solely to the code that was 
used for the authorization request. It is not appropriate to use a coding argument on a pre-authorization appeal. 
No review of the issues of the request was performed by the Plan.  
 
Due to this, the Plan has not provided a list of in-network orthopedic surgeons who are closer to the enrollee 
and more accessible than the requested OON provider. Without any evidence showing that the Plan network 
has accessible providers available, we find that in-network coverage must be extended for this consultation.  
Therefore, we decided that the Plan has to approve in-network coverage for a consultation with an out-of-
network (OON) orthopedic surgeon.   
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft (D4263) provided on May 19, 
2023. 
 
You asked the Plan to pay for the dental services. You say that other providers would not see you because you 
take a blood thinner, and you feel safe with is provider. The Plan denied your request. The Plan says this 
service is only covered when provided by a periodontist. 
 
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 
covered when provided a general dentist. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft (D4263) provided on May 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
March 20, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service March 20, 2023.