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

 
We decided that the Plan does not have to pre-approve continued inpatient behavioral health services (99221). 
 
You asked the Plan to pre-approve continued inpatient behavioral health services. You say that the enrollee's 
continued stay is medically necessary until safe placement can be secured. The Plan denied your request. The 
Plan says the enrollee does not meet criteria for continued inpatient behavioral health services. 
 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 continued inpatient behavioral health 
services. Our reviewer says that the service is not medically necessary. Our physician reviewer found based 
upon review the records provided it was not expected this enrollee would improve in a reasonable period of 
time for the dates in question as she did not have suicidal or homicidal ideation, auditory or visual 
hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. It did 
not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of 
care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or 
others and was compliant with her treatment. The health plans denial of continued inpatient psychiatric 
services is appropriate. This 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 the services were reasonably expected to improve the enrollees condition or for the 
purpose of diagnosis beyond the date in question. We are unable to find an individualized treatment plan 
however the entire record is not present. It did appear that the records were supervised and evaluated by a 
physician. Based upon review the records provided for the admission of this enrollee does not meet the criteria 
for September 06, 2023, forward. She was cooperative/compliant with treatment while not showing any threats 
the 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 continued inpatient behavioral health services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient behavioral health services (99221).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the acupuncture office visits (99211) provided from January 3, 2023, 
through April 4, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the services provided in this case are not 
payable as the provider is not enrolled in the Medicare program.  
 
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. Specifically, the Plan has not provided their contractual coverage policy in this 
case for acupuncture services. The Plan has not substantiated their denial; therefore, we must find in your 
favor. Therefore, we decided that the Plan has to pay for the acupuncture office visits (99211) provided from 
January 3, 2023, through April 4, 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 procedure code 99232 for date of service May 2, 2023, to 
May 12, 2023. 
 
You asked the Plan to pay for procedure code 99232. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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. 
 
In this case, the CPT Code Manual definition of code 99232 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. 
 We find that CPT code 99232 is not supported in the medical record. Specifically, the documentation does not 
include the total time spent on this service. Without a note of time of 35 or more minutes, this code cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of procedure code 99232 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99232 for date of 
service May 2, 2023, to May 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96384 and 96375 billed for date of service 
April 4, 2023. 
 You asked the Plan to pay for procedure codes 96384 and 96375. You say that you disagree with the denial. 
The Plan denied your request. The Plan says payment for codes 96384 and 96375 is bundled into payment for 
code 99152. 
 
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, we have confirmed that codes 
96384 and 96375 are column II codes to column I code 99152. This claim has not been billed with an 
appropriate modifier to bypass the edit. The -59 modifier is not supported as a separate and distinct procedural 
service. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 96384 and 96375 billed for date of service April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nursing facility discharge management 
provided on March 10, 2023. 
 
You asked the Plan to waive the copayment for nursing facility discharge management. You say that you feel 
the cost share applied to service should not be paid or applied due to the mistreatment of the patient during the 
services. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $20 copayment for nursing facility discharge management. This item/service 
falls within the physician/practitioner services, including doctors 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. Therefore, we decided that the Plan 
does not have to waive the copayment for nursing facility discharge management provided on March 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for psychotherapy services provided on June 
15, 2023. 
 
You asked the Plan to waive the copayment for psychotherapy services. You say that you do not understand 
why you are being charged. 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 $20 
copayment for each Medicare-covered individual or group therapy visit. 
 
You have been asked to pay a $20 copayment for psychotherapy services. This item/service falls within the 
each Medicare-covered individual or group therapy visit 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 psychotherapy services provided on June 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient psychiatric stay provided from 
September 7, 2022, to September 15, 2022. 
 
You asked the Plan to waive the copayment for the inpatient psychiatric stay. You say that you were told that 
your stay would be covered. 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 $450 
copayment per day, days 1 to 4, for inpatient hospital mental health care.   
 
 You have been asked to pay a $1800 copayment for the inpatient psychiatric stay ($450 copayment x 4 days = 
$1800). This item/service falls within the inpatient mental health care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the inpatient psychiatric stay provided from September 7, 2022, to 
September 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 
87641, and 87500 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 procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500 are 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. 
 
In this case, the CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. The definition of code 87491 is infectious agent 
detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique. The definition of 
code 87563 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique. The definition of code 87640 is infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, amplified probe technique. The definition of code 87653 is infectious agent detection 
by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique. The definition of code 
87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. The definition of code 87500 is infectious agent detection by nucleic acid (DNA or 
RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique. 
 
We find that CPT codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500 are not supported in the 
medical record. Specifically, the records show that a panel of testing was performed and there is a more 
appropriate, singular code for the services. 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 
procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500 billed for May 5, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from April 11, 2023, to 
April 13, 2023. 
 
You asked the Plan to pay for the medication. You say that these medications were given while you were under 
anesthesia. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from April 11, 2023, to April 13, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotics billed with codes A500-RT-KX, A5500-LT-
KX, A5512-RT-KX, and A5512-LT-KX for March 11, 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 physician order is not valid. 
 The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 
We looked at the file and Medicare rules. The file shows that the order in the submitted documentation is not 
valid because it does not list a description of the items ordered. Therefore, we decided that the Plan does not 
have to pay for the orthotics billed with codes A500-RT-KX, A5500-LT-KX, A5512-RT-KX, and A5512-LT-
KX for March 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a walking boot provided on October 18, 
2022, and an arthrodesis procedure provided on October 26, 2022. 
 
You asked the Plan to reduce the coinsurance for a walking boot and an arthrodesis procedure. You say that 
you were told that you would only have a $400 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 14% 
coinsurance for in-network durable medical equipment. Your contract with the Plan also clearly says that you 
must pay 30% coinsurance for out-of-network surgery services provided at an ambulatory surgical center. 
 
You have been asked to pay $42.50, which is 14% coinsurance of the allowed amount for a walking boot 
provided on October 18, 2022 ($303.55 allowed amount x 14% = $42.50). This item falls within the durable 
medical equipment and related supplies benefit category. You have also been asked to pay $2,107.63, which is 
30% coinsurance of the allowed amount for the arthrodesis procedure provided on October 26, 2022 ($7,025.41 
allowed amount x 30% = $2,107.63). This service falls within the outpatient surgery, including services 
provided at 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. Therefore, we decided that the Plan does not have to reduce the coinsurance 
for a walking boot provided on October 18, 2022, and an arthrodesis procedure provided on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 for date of service February 27, 2023. 
 
You asked the Plan to pay for procedure code 99223. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the documentation does not 
support the time spent on this encounter. Without a note of 75 or more minutes, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of procedure code 99223 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99223 for date of service 
February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and debridement provided on April 20, 2023. 
 
You asked the Plan to pay for the office visit and debridement. You say that you are appealing the denial with 
supporting documentation. 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 office visit and 
debridement provided on April 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the care management services provided on June 08, 2023. 
 
You asked the Plan to pay for the care management 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 care management 
services provided on June 08, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from April 14, 2023, 
to May 5, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that the facility did a poor job 
communicating and did not advise the enrollee they would be charged if the stay went beyond 20 days. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 copayment for days 1 to 20 and a $172 copayment for days 21 to 100 for SNF care.  
 
 
  The enrollee has been asked to pay a $172 copayment for a SNF stay. This item/service falls within the SNF 
care benefit category. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a SNF stay provided 
from April 14, 2023, to May 5, 2023.  
 
Your complaint about poor communication from the facility is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950), a porcelain/ceramic crown 
(D2740) and a resin-based composite (D2331). 
 
You asked the Plan to pre-approve the dental services. You say that to your recollection, your only dental visit 
was on April 6, 2023, for a cleaning. You also say that you do not believe you have reached your $2,000 limit. 
The Plan denied your request. The Plan says your benefit for the requested item or service 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 your benefit for core buildup (D2950), a porcelain/ceramic crown (D2740) was exhausted on date of 
service April 6, 2023. The record also shows that the maximum $2,000 allowance was exhausted on this same 
date of service. Therefore, we decided that the Plan does not have to pre-approve core buildup (D2950), a 
porcelain/ceramic crown (D2740) and a resin-based composite (D2331).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic procedures provided by a chiropractor on July 
26, 2021, to September 29, 2021. 
 
You asked the Plan to pay for the therapeutic procedures. You say that you thought the services would be 
covered. The Plan denied your request. The Plan says that the only covered chiropractic service is manual 
manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the therapeutic procedures provided by a chiropractor on July 26, 2021, to 
September 29, 2021.