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

 
We decided that the Plan does not have to pay for procedure codes 44146 and 45300 rendered on June 15, 
2022. 
 
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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 44146: 
 
Colectomy, partial; with coloproctostomy (low pelvic anastomosis), with colostomy  
CPT 45300: 
 
Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing 
(separate procedure) 
 
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 CPT code 44146 is not supported; 
the elements of the code description are not met by the documentation. The colectomy was performed at a 
separate encounter and no colostomy was performed. There is a more specific code for the procedure 
performed. Additionally, CPT code 45300 is not supported. A rigid diagnostic proctosigmoidoscopy was not 
performed. The scope was to evaluate the procedure performed, not a separate diagnostic evaluation. This is 
included in the main procedure. 
 
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 44146 and 45300 rendered on June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (procedure code 99220) rendered on 
August 1, 2022. 
 
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 Current Procedural Terminology (CPT) 99220-25 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 the provided documentation from 
the date of service describes the enrollee has having been admitted with seizure and weakness but was then 
stable. The history was problem-focused and brief, but not comprehensive. The physical exam was detailed but not comprehensive. The enrollee was stable and started on Keppra. The enrollee was monitored and discharged 
home the same day as this note. The records do not support medical decision-making of high complexity for 
this date. 
 
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 initial observation care (procedure code 99220) rendered on August 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment purchased on February 2, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the purchase of oxygen equipment is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is not made for the purchase of oxygen 
equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen equipment have not been met. Specifically, Medicare only covers the rental of oxygen 
equipment, you purchased the equipment. Therefore, we decided that the Plan does not have to pay for the 
oxygen equipment purchased on February 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on January 19, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary.  The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 26, 2023. 
 
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 January 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from 
July 6, 2023, and forward. 
 
You asked the Plan to pre-approve the continuation of inpatient mental health care from July 6, 2023, and 
forward. You say that the continuation of inpatient mental health care from July 6, 2023, and forward is 
medically necessary.  The Plan denied your request. The Plan says the continuation of inpatient mental health 
care from July 6, 2023, and forward is 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 the continuation of inpatient mental 
health care from July 6, 2023, and forward. Our reviewer says that the continuation of inpatient mental health 
care from July 6, 2023, and forward is not medically necessary.  Our physician reviewer found the enrollee did 
not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to 
herself or others and does not have auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services were reasonably expected to 
improve the enrollees condition or for the purpose of diagnosis beyond the date in question. This enrollee was 
treated under an individualized treatment plan found in the record. It did appear that the records were 
supervised and evaluated by a physician. Based upon review of the records provided, this enrollee does not 
meet the criteria for continued inpatient mental health care from July 6, 2023, and forward as this enrollee was 
not shown to be a danger to herself or others, no delusions, auditory or visual hallucinations noted. She was 
cooperative/compliant with treatment while not showing any threats to safety. 
 
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 continuation of inpatient mental health care from July 6, 2023, and forward 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of 
inpatient mental health care from July 6, 2023, and forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthosis billed with code L1690 for January 9, 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 the claim was not billed within six months of the written order. 
 
The Plan must follow Medicare rules. The rules say that a written order prior to delivery (WOPD) must be 
completed within six (6) months after the required face-to-face encounter.  
 
We looked at the file and Medicare rules. The file shows that the WOPD was not received within six months of 
the initial encounter. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the orthosis billed with code 
L1690 for January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 and supplies. 
 
You asked the Plan to pre-approve a Dexcom G7 and supplies. You say that the request is medically necessary 
because the enrollee's diabetes is uncontrolled. The Plan denied your request. The Plan says the enrollee does 
not meet the required criteria. 
 
The Plan follows 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 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 Dexcom G7 and supplies. Our reviewer 
says that the enrollee does not meet Medicare criteria for a therapeutic continuous glucose monitor (CGM). Our 
physician reviewer found the records do not show a list of blood sugars and no mention of low blood sugars. It 
appears as if the enrollee uses metformin aloe and not insulin; however, if the enrollee is using insulin this 
should be clearly stated and the case re-reviewed. We are not told why traditional glucometer use with finger 
sticks would not suffice for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Dexcom G7 and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G7 and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
February 13, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. 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 $30 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $30 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 a specialist office visit provided on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network back injection provided on 
January 10, 2023. 
 
You asked the Plan to waive the copayment for an in-network injection. You say that this was performed in an 
office, not a hospital room. You should not have to pay these large 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 $300 
copayment for surgery services, and a 20% coinsurance for Medicare Part B drugs. 
 
You have a $300 copayment, and a 20% coinsurance resulting in $76.74 ($300 + $76.74 = $376.74). You have been asked to pay a $376.74 copayment for an in-network injection. This item/service falls within the 
surgery services and Medicare Part B prescription drugs 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 back injection provided on January 10, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the lead wires (A4557) provided September 23, 2023. 
 
You asked the Plan to pay for lead wires. You say that A4557 is not inclusive to A4595 and is separately 
reimbursable. The Plan denied your request. The Plan says that this procedure has been billed and allowed the 
maximum number of times allowed by our payment policy. 
 
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. the Plan has not provided any documentation that supports that this service was 
already paid. The Plan has not substantiated their reason to continue to deny. Therefore, we decided that the 
Plan has to pay for the lead wires (A4557) provided September 23, 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 pay for a screening mammography provided on February 15, 2023. 
 
You asked the Plan to pay for a screening mammography. You say that this was medically necessary and 
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 a screening 
mammography provided on February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each office visit provided on August 17, 
2022, to November 17, 2022. 
 
You asked the Plan to reduce the copayment for each office visit. You say that you think that the copayment 
should be lower. 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 $45 
copayment for specialist office visits. 
 
You have been asked to pay a $45 copayment for each office visit. This item/service falls within the specialist 
office visits 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 amount you owe is $90 ($45 copayment x 2 visits = $90). Therefore, we decided that the Plan 
does not have to reduce the copayment for each office visit provided on August 17, 2022, to November 17, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incision and drainage provided on August 24, 2022. 
 
You asked the Plan to pay for incision and drainage. 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 incision and drainage 
provided on August 24, 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 the enrollee would benefit from inpatient 
rehabilitation to improve functional mobility, activities of daily living, and to reduce readmission and caregiver 
burden. The Plan denied your request. The Plan says criteria for admission to the acute IRF setting have not 
been met. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 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 the lab services provided on January 11, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the lab services. You say that this is supported in the records. The Plan denied 
your request. The Plan says enrollees must receive their care from a network provider. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on January 11, 2023, by 
an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
March 05, 2023, to March 07, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you were treated 
poorly by the provider. 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 $125 
copayment for emergency care. 
 
You have been asked to pay a $125 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 March 05, 2023, to March 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle continuous glucose monitor (CGM) Kit 
Sensor. 
 
You asked the Plan to pre-approve a Freestyle CGM Kit Sensor. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the enrollee is not on insulin and does not 
have documentation of problematic hypoglycemia, a CGM is not covered under current Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a Freestyle CGM Kit Sensor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Freestyle continuous glucose monitor (CGM) Kit Sensor.