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

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from November 16, 2022, 
through November 18, 2022. 
 
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 acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that based on the documentation provided, this hospitalization qualifies for inpatient payment under the 
two-midnight rule. The enrollee presented with diarrhea. She was found to have diverticulitis, electrolyte 
derangements and prerenal azotemia. The documentation indicates a reasonable belief that, at the time of 
admission, two midnights of care would be required to further evaluate and treat the 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 these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from November 16, 2022, through November 18, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service October 27, 
2022.  You asked the Plan to pay for procedure code 88374. You say that the lab reports validate the number of units 
billed. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88374 is 5. The MAI value for this code is 3. You billed 7units of this 
code, exceeding the MUE. The documentation provided does not indicate why the excess units were needed in 
this case. Based on this information, we decided that Medicare rules for coverage of procedure code 88374 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88374 billed 
for date of service October 27, 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 medical records show medical necessity for 
admission to an IRF. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the new patient office visit provided by an 
in-network provider on February 15, 2023. 
 
You asked the Plan to waive the deductible for the office visit. You say that you do not think you owe anything 
for this service. 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. Your 
contract with the Plan says that there is a $675 deductible which applies to physician/practitioner services, 
including doctor's office visits.  
 
 
 
 
 
 You have been asked to pay a $172.05 deductible for the office visit. The item or service you asked the Plan to 
waive the deductible for falls within the physician/practitioner services, including doctor's office visits benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $675 
deductible which applies to physician/practitioner services, including doctor's office visits. This cost sharing is 
a contractual obligation that had not been met at the time the office visit was provided on February 15, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the new patient office visit 
provided by an in-network provider on February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections. 
 
You asked the Plan to pre-approve injections. You say that you have limited movement and are in excruciating 
pain. The Plan denied your request. The Plan says that the facet joint injections are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve injections. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that you have a history of chronic 
neck pain due to cervical spondylosis, without myelopathy or radiculopathy. You have been treated with 
medications including opiates, and C5-C6 facet joint injections which only provided 70 % relief of pain. 
However, the records do not show that you had at least 80% pain relief after the first diagnostic facet joint 
procedure on May 17, 2023. Therefore, you do not meet the LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on November 2, 2022, to 
November 23, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the therapy services provided by an OON provider. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide OON care. 
 
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 
item/service 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 therapy services provided on November 2, 
2022, to November 23, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of chest (71250). 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that this is medically necessary. The Plan 
denied your request. The Plan says that this is too soon for a follow-up CT scan. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan of the chest. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found an 8mm solid nodule in a high- 
risk patient such as this may be followed with a repeat CT in 3-6 months so the requested CT to follow a 
nodule seen on April 27, 2023, is reasonable. The CT scan of April 27, 2023, showed ground glass peripheral 
opacities which may be inflammatory and the request for a 3 month follow-up after treatment is reasonable as 
well. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the chest have been met. Therefore, we decided that the Plan has 
to pre-approve a computed tomography (CT) scan of chest (71250).  
 
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 office visit provided on May 17, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that you did not have any other insurance 
coverage on this date of service. You also say that this claim should have paid. 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 the office visit provided on May 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99215), aspiration and/or injection of large 
joint or joint capsule (20610), and an injection (J1885) provided on January 31, 2023, by an out-of-network 
(OON) provider.  
 You asked the Plan to pay for an office visit, aspiration and/or injection of large joint or joint capsule, and an 
injection with an out-of-network provider. You say that you want the Plan to pay for the services. The Plan 
denied your request. The Plan says this provider is not a network provider and based on the documentation 
submitted, the services rendered were not urgent or emergent, nor were they approved in advance by 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 
item/service 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 an office visit (99215), aspiration and/or injection 
of large joint or joint capsule (20610), and an injection (J1885) provided on January 31, 2023, by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the specialist office visit provided on February 8, 
2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you never had a to pay a 
copayment for this injection before. The Plan denied your request. The Plan says that The Plan says that the 
cost share was applied correctly. 
 
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 a complete Evidence of Coverage showing how the 
cost share was applied. Therefore, we decided that the Plan has to waive the copayment for the specialist office 
visit provided on February 8, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on February 7, 2023. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport, and ground 
mileage. You say that due to the enrollee's condition at the time of transport, any other means of transport 
would be unsafe. The Plan denied your request. The Plan says the ambulance transport was not medically 
necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport, and ground mileage. Our reviewer says that the service ambulance transport services 
were not medically necessary.  Our physician reviewer found the record indicates that the enrollee was transported from the hospital to a 
rehabilitation facility via stretcher van. The record does not indicate that the enrollee's clinical condition was 
such that other methods of transport, such as stretcher, are contraindicated or that the expertise, services and 
lifesaving and life-sustaining equipment that only a fully equipped ambulance can provider was required. The 
record provided does not establish that medical necessity and reasonableness, as defined by Medicare rules, of 
the required service. 
 
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 ambulance service, basic life support, non-emergency transport, and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, non-emergency transport, and ground mileage provided on February 7, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes R0070 and Q0092 billed for date of service October 
29, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim was billed with appropriate codes. The 
Plan denied your request. The Plan says that the provider did not bill as required by coding regulations. 
 
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 find that CPT codes R0070 and Q0092 are payable when billed by a portable x-ray supplier. Based on this 
information, we decided that Medicare rules for coverage have been met. Therefore, we decided that the Plan 
has to pay for procedure codes R0070 and Q0092 billed for date of service October 29, 2022.  
 
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: Favorable

 
We decided that the Plan has to pre-approve 4 additional home health physical therapy (PT) visits (G0151 x4). 
 
You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says that the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are medically reasonable and necessary. Our physician reviewer found the enrollee 
underwent a right sided knee arthroplasty and has been receiving home health physical therapy. She has 
improved in terms of her bed mobility, transfers, and ability to ambulate, but continues to require some 
assistance with ambulation with a rear walker due to weakness and risk for falling. Continued home health 
physical therapy is important in maximizing her strength and transitioning her safely to a home exercise 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to 
pre-approve 4 additional home health physical therapy (PT) visits (G0151 x4).  
   
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided by an in-
network provider on January 29, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you do not agree 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 $250 
copayment per one-way trip for in and out-of-network ambulance services. 
 
 
 You have been asked to pay a $250 copayment for the ambulance services. These items/services fall within the 
ambulance 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 ambulance 
services provided by an in-network provider on January 29, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for date of service February 17, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the weekly billing should be coded 323. The 
Plan denied your request. The Plan says  the type of bill code is not valid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 The claim at issue was submitted with type of bill code 323. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home health care billed for date of service February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service February 15, 2022. 
 
You asked the Plan to pay for the billed services. You say that you were not provided with the correct diagnosis 
codes. The Plan denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the billed services was not filed until February 20, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the lab testing billed for date of service February 15, 2022.