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

 
We decided that the Plan does not have to pay for the nursing facility care and laboratory service provided on 
April 19, 2023. 
 
You asked the Plan to pay for the nursing facility care and laboratory service. 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 nursing facility care 
and laboratory service provided on April 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on May 31, 2023. 
 
You asked the Plan to pay for the laboratory service. 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 laboratory service 
provided on May 31, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on June 
23, 2023. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you left without any 
medical services being performed. 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 $95 
copayment for in and out-of-network emergency care visits. 
 
You have been asked to pay a $95 copayment for an emergency room visit. This item/service falls within the in 
and out-of-network emergency care 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 an emergency room visit provided on June 23, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 provided on April 18, 2023. 
 
You asked the Plan to pay for procedure code 95937. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as 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 code 95937 is Neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
We find that CPT code 95937 is not supported in the medical record. Train of Four testing does not fit the 
criteria set by CMS and insurance carriers for CPT 95937. There is no separate code for Train of Four 
monitoring. Therefore, it would be inappropriate to bill the neuromuscular junction testing code for Train of 
Four monitoring. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 95937 provided on April 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care services (99223) provided on April 24, 
2023. 
 
You asked the Plan to pay for the initial hospital care services. You say that the services provided were 
emergent in nature. The Plan denied your request. The Plan says the services rendered were not urgent or 
emergent and were not approved in advance by a network provider. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 initial hospital care services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has 
metastatic lung cancer and sought medical care for a fever. On initial evaluation, the enrollee's pulse was 106, 
respiratory rate was 18, blood pressure 142/85, pulse oximetry 97%, temperature 37.2 degrees C (99 F), and he 
had 7/10 pain in his right shoulder. His white blood cell count was normal, total bilirubin was slightly elevated 
at 0.4 mg/dL. Per oral measurement at home, the enrollee's fever had been up to 102 degrees F. In the physician 
assessment, he was noted to be chronically ill-appearing, but in no acute distress and with a regular heart rate 
and rhythm. On multiple assessments, he is documented as resting, hemodynamically stable, including the 
statement, "patient's condition remained stable. Vitals stable." There is no documentation to suggest instability. 
It would appear the patient could have been transferred at the time the note was signed by the attending (April 
24, 2023, at 22:28). 
 
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 initial hospital care services have not been met. Therefore, we decided that 
the Plan does not have to pay for initial hospital care services (99223) provided on April 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nebulizer provided on May 15, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the nebulizer. You say that this claim did not require prior authorization. The 
Plan denied your request. The Plan says the enrollee has no out-of-network benefits to cover this item. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has a POS option to use either network providers or out-of-network providers for certain covered services. The Plan contract also says that out-of-network durable medical equipment is not covered. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for this item. Therefore, we 
decided that the Plan does not have to pay for the nebulizer provided on May 15, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the arthrocentesis provided on June 07, 
2023, to June 13, 2023. 
 
You asked the Plan to pay for the office visit and the arthrocentesis. 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 office visit and the 
arthrocentesis provided on June 07, 2023, to June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 15, 2023. 
 
You asked the Plan to pay for the office visit. 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 office visit provided 
on July 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 26, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are asking for the medical records to be 
reviewed. 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 June 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric inpatient hospitalization provided on April 
01, 2023, to April 30, 2023. 
 
You asked the Plan to pay for the psychiatric inpatient hospitalization. You say that you are requesting 
reconsideration stating to review the medical records and reprocess for payment. 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 psychiatric inpatient 
hospitalization provided on April 01, 2023, to April 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation and debridement of nail provided 
on May 15, 2023. 
 
You asked the Plan to pay for home visit for evaluation and debridement of nail. You say that you believed that 
all the necessary information at the time of your initial review was not received. 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 home visit for 
evaluation and debridement of nail provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network outpatient diagnostic 
tests provided on April 01, 2022, to April 14, 2022. 
 
You asked the Plan to waive the coinsurance for an out-of-network outpatient diagnostic tests. You say that 
you disagree with the coinsurance. 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 30% 
coinsurance for an out-of-network outpatient diagnostic tests/Medicare-covered diagnostic radiological services. 
 
You have been asked to pay 30% coinsurance for an out-of-network outpatient diagnostic tests. This item/service falls within the an out-of-network outpatient diagnostic tests/Medicare-covered diagnostic 
radiological services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an out-of-network 
outpatient diagnostic tests provided on April 01, 2022, to April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for presbyopia correcting function of intraocular lens (V2788) 
provided from May 2, 2023, to May 16, 2023. 
 
You asked the Plan to pay for presbyopia correcting function of intraocular lens (V2788). You say that you 
were advised by the provider that this service was covered. The Plan denied your request. The Plan says 
presbyopia correcting function of intraocular lens (V2788) is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL.  
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for presbyopia correcting 
function of intraocular lens (V2788) provided from May 2, 2023, to May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on May 
19, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you have disputed the 
copayment for this service in the past. 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 specialist physician/practitioner services. 
 
You have been asked to pay a $30 copayment for the specialist office visit. This item/service falls within the 
specialist physician/practitioner services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the specialist office visit provided on May 19, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve aquatic therapy. 
 
You asked the Plan to pre-approve aquatic therapy. You say that you are requesting approval for therapy with 
out-of-network providers to treat chronic back and knee pain. The Plan denied your request. The Plan says that 
there is a lack of efficacy for the requested therapy. Land based therapy for the knee and back are 
recommended. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 aquatic therapy. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has chronic low back pain with lumbar radiculopathy, a history of lumbar 
laminectomy, and bilateral knee osteoarthritis. These conditions are painful and limit the enrollee's function. 
Given that the enrollee has failed to respond to injections, medication and land based physical therapy, the 
aquatic therapy program may be considered reasonable. If there are no in-network providers who perform 
aquatic therapy, the Plan must approve for the enrollee to receive the services by an out-of-network provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aquatic therapy have been met. Therefore, we decided that the Plan has to pre-
approve aquatic therapy.  
 
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 the chronic care management services and the subsequent 
nursing facility care provided on March 28, 2023. 
 
You asked the Plan to pay for the chronic care management services and the subsequent nursing facility care. 
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 chronic care 
management services and the subsequent nursing facility care provided on March 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on June 08, 2023. 
 
You asked the Plan to pay for the laboratory service. 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 laboratory service 
provided on June 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for professional services for the administration of anti-infective 
provided on June 10, 2023. 
 
You asked the Plan to pay for professional services for the administration of anti-infective. You say that the 
services were medically necessary. 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 professional services for 
the administration of anti-infective provided on June 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telephone evaluation and management service provided on 
June 22, 2023. 
 
You asked the Plan to pay for telephone evaluation and management service. 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 telephone evaluation and 
management service provided on June 22, 2023.