Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0260 billed for date of service July 10, 
2023. 
 You asked the Plan to pay for the billed service. You say that the codes were verified. The Plan denied your 
request. The Plan says the diagnosis code at issue is not appropriate as a primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code Z99.3, defined as 
dependence on wheelchair. This code is not an appropriate primary diagnosis as the code has a Code first note 
indicating to code the underlying condition first, and the Z99 diagnosis code group has the code definition 
includes in diseases classified elsewhere which means it is a manifestation code. Based on this information, 
we decided that Medicare rules for payment of this claim have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code E0260 billed for date of service July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic treatment (98941) provided on September 06, 
2023. 
 
You asked the Plan to pay for chiropractic treatment (98941). You say that the services at issue were a medical 
necessity for the enrollee. 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 chiropractic treatment 
(98941) provided on September 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and garments 
(E0673) provided on August 17, 2023. 
 
You asked the Plan to pay for the pneumatic compression device and garments. You say that this device was 
provided for use during the patient's surgery. The Plan denied your request. The Plan says equipment used in a 
facility for a procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) and garments (E0673) provided on August 17, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve home health services. You say that the services at issue are a necessity for 
your care. The Plan denied your request. The Plan says rules for coverage for OON services have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home health services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was 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 the laboratory services 
provided on October 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 10, 
2023, through August 12, 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 the acute inpatient hospital care provided was 
not medically necessary.  
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 
acute inpatient hospital care provided was not medically necessary. Our physician reviewer found that the 
enrollee was discharged from the same hospital on August 9, 2023 after a weeklong stay for sepsis and a 
complicated urinary tract infection. The enrollee was discharged to a sub-acute rehabilitation facility for 
strengthening. One day later, on August 10, 2023, the enrollee was brought back to the Emergency Department. 
She was found to meet SIRS Criteria (Systemic Inflammatory Response Syndrome), and, again, was diagnosed 
with a complicated urinary tract infection. She was re-admitted as an inpatient and was given fluid replacement 
and intravenous antibiotics. The review has determined that the readmission was the result from a premature 
discharge from the same hospital. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from August 10, 2023, through August 12, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve sensors for a continuous glucose monitor (CGM) 
 
You asked the Plan to pre-approve sensors for a CGM. You say that it is medically necessary to get the sensors. 
The Plan denied your request. The Plan says that the denial of authorization is correct because the enrollee's 
physician did not order the CGM and the Medicare criteria for a CGM was not met. 
 
The Plan must follow 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 sensors for a CGM. Our reviewer says 
that the CGM coverage criteria was met. Our physician reviewer found that the enrollee is prescribed Lantus 
and Lispro insulins and hence meets the provided criteria for CGM coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sensors for a CGM have been met. Therefore, we decided that the Plan has to 
pre-approve sensors for a continuous glucose monitor (CGM)  
  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #22 and #23. 
 
You asked the Plan to pre-approve the dental services. You say that the crowns are medically necessary. The 
Plan denied your request. The Plan says that the denial of authorization for these services is correct, because 
there is no dental decay, and the tooth structure is intact. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says 
that the crown (D2740) for teeth #22 and #23 are medically necessary. Our physician reviewer found that the 
documentation indicates the presence of significant coronal breakdown of teeth #22 and #23.  It is medically 
reasonable and necessary to place crown restorations to prevent additional breakdown and to restore adequate 
function. Other mandibular anterior teeth have been crowned and the bone support is good. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve a crown (D2740) for tooth #22 and #23.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac catheterization and self-administered drugs provided 
on March 7, 2023. 
 
You asked the Plan to pay for cardiac catheterization and self-administered drugs. You say that you do not have 
this kind of money. 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 50% 
coinsurance for out-of-network outpatient hospital services, up to a $5,450 combined maximum out-of-pocket 
(MOOP) amount for 2023. At the time this claim was processed, $666.93 of the $5,450 combined MOOP 
amount had been met. The allowed amount of this claim is $21,739.92, resulting in a coinsurance amount of 
$4,783.07 because this amount met the $5,450 combined MOOP for 2023. 
 
You have been asked to pay 50% coinsurance for cardiac catheterization and self-administered drugs. This 
item/service falls within the Outpatient Surgery, Including Services Provided at Hospital Facilities and 
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. Additionally, the self-administered drugs billed are not among those covered by Medicare 
Part B. Therefore, we decided that the Plan does not have to pay for cardiac catheterization and self-
administered drugs provided on March 7, 2023.  
 
Benefits for cardiac catheterization and self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) and the bone replacement graft 
(D7953) for tooth #18 provided by an unassigned provider on March 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a refund for March 8, 2022. 
The Plan denied your request. The Plan says the extraction was received from an unassigned provider and are 
not covered by your supplemental benefits. Also, the bone replacement graft is not covered by the Plan. 
 
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. 
 
  The record shows you received the extraction from an unassigned provider. Though the Plan offers a dental 
benefit in excess of Medicare coverage, the extraction is not covered under this benefit when received from an 
out-of-network provider. The bone replacement graft is not a covered under the Plan's dental benefit. 
Therefore, we decided that the Plan does not have to pay for an extraction (D7210) and the bone replacement 
graft (D7953) for tooth #18 provided by an unassigned provider on March 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the travel allowance one way in connection with medically 
necessary laboratory specimen collection (P9604) provided August 14, 2023. 
 
You asked the Plan to pay for the travel allowance. You say that please review the attached travel log to 
support the claim. The Plan denied your request. The Plan says does not meet coding standards. The 
documentation did not indicate that a technician drew the specimen. 
 
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 P9603 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated trip charge. 
 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 travel allowance. Our reviewer says that the service is not 
supported in the documents received. Our reviewer found P9604 should have a modifier for round trip and also 
for place of service to show as home or nursing facility. 
 
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 travel allowance have not been met. Therefore, we decided that the Plan 
does not have to pay for the travel allowance one way in connection with medically necessary laboratory 
specimen collection (P9604) provided August 14, 2023.
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 provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines and 
the information we have about the enrollee's condition, they do not meet all of the factors for IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for non-operative management of a humerus fracture and surgical management of a hip fracture 
after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service June 7, 2023, 
to June 8, 2023. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT/HCPCS code. 
 
We find that the home health services at issue do not meet criteria for payment. Specifically, the services have 
been reported without a required G code to represent a visit by the appropriate HH care discipline(s). Based on 
this information, we decided that Medicare rules for coverage of home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services billed for dates of service 
June 7, 2023, to June 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient surgery provided on August 
16, 2023. 
 
You asked the Plan to waive the coinsurance for the outpatient surgery. You say that you did not know the 
provider was out-of-network, if you had, you would not have had the surgery. 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 10% 
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay 10% coinsurance for the outpatient surgery. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and 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. The 
total you owe is $775.68 ($7,756.83 allowed amount x 10% out-of-network = $775.68). Therefore, we decided 
that the Plan does not have to waive the coinsurance for the outpatient surgery provided on August 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 30, 2023, billed with 
procedure code 00350-QX-P4. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this service is included in the payment of another 
procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for anesthesia services is determined 
based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the 
actual anesthesia time of the multiple procedures.  
 
We looked at the file and Medicare rules. This claim appropriately denied as another anesthesia code was 
reported on this date of service. Based on this information, we decided that Medicare rules for coverage of the 
practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on June 30, 2023, billed with procedure code 00350-QX-P4.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 25, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on January 25, 2023.