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

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
December 12, 2022, to December 16, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment per day for days 1-7 for inpatient hospital care.  
 
You have been asked to pay a $250 copayment per day for days 1-7 for inpatient hospital care. You are being 
asked to pay $250 per day for days 1-7. The total amount you are being asked to pay is $1,000 ($250 x 4 days = 
$1,000).This item/service falls within the inpatient hospital 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 inpatient hospital care provided on December 12, 2022, to December 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that  the enrollee is in need of long-term 
acute care hospital admission. The Plan denied your request. The Plan says the enrollee's records do not show 
there have been three or more tries to be able to breathe on own (breathing trials) and breathing did not get 
better during the breathing trials. The enrollee may safely receive this care in another setting, such as in your 
current acute care facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not available at the current health care setting being offered by the health plan. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you have had several strokes and can't care for 
yourself. You say you cannot walk unassisted and cannot safely go home without therapy. The Plan denied 
your request. The Plan says a SNF admission is not supported based on the records received. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0402-59 billed for date of service October 
21, 2022. 
 
You asked the Plan to pay for the billed services. You say that the code is separately payable. The Plan denied 
your request. The Plan says the 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 code. We looked at the file and the rules. We find that the evaluation and management (E/M) code G0402 was billed 
with the -59 modifier. Modifier 59 is used to identify procedures and services, other than evaluation and 
management services, that are not normally reported together, but are appropriate under circumstances.  
Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code G0402-59 
billed for date of service October 21, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for diabetic supplies provided on January 26, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you went in-network. The Plan denied your 
request. The Plan says that we consider these services experimental. 
 
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. Medical records were not provided for the enrollee. Therefore, we decided that 
the Plan has to pay for diabetic supplies provided on January 26, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36140, 36247, & 75716 provided on 
January 6, 2023. 
 
You asked the Plan to pay for procedure codes 36140, 36247, & 75716. You say that this service was 
medically necessary. The Plan denied your request. The Plan says the codes 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 definitions of codes 36140, 36247, & 75716 are Introduction of a needle or 
intracatheter, into an upper or lower extremity artery, selective catheter placement, into arterial system, for a 
placement in the initial third order or more selective abdominal, pelvic, or lower extremity artery branch, 
within a vascular family, and Radiological supervision and interpretation of an angiography for bilateral 
extremity studies.  
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 procedure codes 36140, 36247, & 75716. Our reviewer says 
that the billed services are not supported by the records. Our reviewer found the operative report does not 
include documentation of Introduction of a needle or intracatheter, into an upper or lower extremity artery. 
Procedure codes 36247 & 75716 are not described in the records provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 36140, 36247, & 75716 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 36140, 36247, & 75716 provided on January 6, 
2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on March 13, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this provider does 
not participate in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare is creating additional flexibilities to 
allow licensed independent freestanding emergency departments (EDs) to participate in Medicare and 
Medicaid to help address the urgent need to increase hospital capacity to provide care to patients. 
 
We looked at the file and Medicare rules. The services in this case were provided during the COVID-19 
emergency period, during which freestanding emergency departments (EDs) were allowed participate in 
Medicare to help address the urgent need to increase hospital capacity to provide care to patients. Based on this 
information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided 
that the Plan has to pay for the services provided on March 13, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  two alveoloplasties (D7321) provided on February 14, 2023. 
 
You asked the Plan to pay for  two alveoloplasties. You say that this is medically necessary. The Plan denied 
your request. The Plan says if you would like possible coverage please send to your new plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for  two alveoloplasties (D7321) 
provided on February 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter. 
 
You asked the Plan to pre-approve a scooter. You say that you are alone most of the time and need a scooter 
when you go out on your own. You also say that you do not want to rely on others when you want to get 
around, and your power wheelchair is too big to bring anywhere.  The Plan denied your request. The Plan says 
you asked for a scooter for community use. The Plan also says that there is no evidence that a scooter is 
medically necessary. 
 
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 pre-approve a scooter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) visit 
provided on March 01, 2023. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) visit. You say that you 
fell on the hospital grounds, therefore, this copayment should be waived. 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 emergency care. 
 
You have been asked to pay a $95 copayment for an in-network emergency room (ER) visit. This item/service 
falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an in-network emergency room (ER) visit provided on March 01, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral exam (D0120), a limited oral evaluation 
(D0140), a cleaning (D1110), and a resin-based composite (D2330 and D2393) for tooth #27 and #30 provided 
by an out-of-network provider on January 18, 2023, and April 12, 2023. 
 
You asked the Plan to pay more for the dental services. You say that there are no in-network providers, and you 
would like the dental services changed to an in-network benefit level. The Plan denied your request. The Plan 
says you are responsible for any charged amount above the Plans cost-sharing amount when your services are 
received from an out-of-network provider. Also, the proper cost share was applied. 
 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. 
 
For the periodic oral exam, the total amount billed was $63 and the total allowed amount was $26.75 leaving a 
difference of $36.25 ($63 billed - $26.75 allowed). The total amount billed for the limited oral evaluation was 
$105 and the total allowed amount was $39.83 leaving a difference of $65.17 ($105 billed - $39.83 allowed). 
The total amount billed for the cleaning was $126 and the total allowed amount was $50.52 leaving a 
difference of $75.48 ($126 billed - $50.52 allowed). The total amount billed for the resin-based composite 
(D2330) for tooth #27 was $158 and the total allowed amount was $84.81 leaving a difference of $73.19 ($158 
billed - $84.81 allowed). The total coinsurance amount was $16.92 ($84.81 allowed x 20% coinsurance). The 
total you are liable for was $90.15 ($73.19 difference + $16.92 coinsurance). The total amount billed for the 
resin-based composite (D2393) for tooth #30 was $305 and the total allowed amount was $150.93 leaving a 
difference of $154.07 ($305 billed - $150.93 allowed). There was a $100 deductible charged leaving the 
remaining allowed amount to $50.93 ($150.93 allowed - $100 deductible). The total coinsurance amount was 
$10.19 ($50.93 allowed after deductible x 20% coinsurance). The total you are liable for was $264.26 ($154.07 
difference + $100 deductible + $10.19 coinsurance). 
 
You have been asked to pay a 20% coinsurance, the deductible, and the difference between the out-of-network 
providers charges and the Plans payment. 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 pay more for a periodic 
oral exam (D0120), a limited oral evaluation (D0140), a cleaning (D1110), and a resin-based composite 
(D2330 and D2393) for tooth #27 and #30 provided by an out-of-network provider on January 18, 2023, and 
April 12, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from September 
12, 2022, to October 11, 2022. 
 You asked the Plan to pay for SNF care. You say that the services are coverable under Medicare guidelines. 
The Plan denied your request. The Plan says the SNF services do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from September 12, 2022, to October 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total disc arthroplasty. 
 
You asked the Plan to pre-approve a total disc arthroplasty. You say that you are in a lot of pain. The Plan 
denied your request. The Plan says this surgery is 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 a total disc arthroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are limited large-scale, long-term references showing the safety and efficacy of 
the requested surgery in this clinical setting. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
lumbar total disc arthroplasty, in this case, is not medically reasonable or necessary.  
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 total disc arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total disc arthroplasty.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service August 7, 
2022, to September 5, 2022. 
 
You asked the Plan to pay for the billed services. You say that the NOA was late but submitted with a KX 
modifier. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 8, 2022. The NOA was not received by the Plan until September 8, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. The records do not document a valid exception to waive the consequences of a timely-filed 
NOA. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health care billed for dates of service 
August 7, 2022, to September 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87631, 94761, 99072) provided on June 22, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue 
(87631), the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable 
and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and 
the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of code 87631 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 procedure code. 
 
We find that procedure code 94761 has a status indicator of T on the Physician Fee Schedule. Since other 
services payable under the physician fee schedule are billed on the same date, this service is bundled into 
payment for the paid services. We also find that procedure code 99072 has a status indicator of B on the 
Physician Fee Schedule. This means that procedure code 99072 is not separately payable. Based on this 
information, we decided that Medicare rules for coverage of codes 94761 and 99072 have not been met. 
Therefore, we decided that the Plan does not have to pay for the services (87631, 94761, 99072) provided on 
June 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve chiropractic care. You say that you want to see a chiropractor. The Plan 
denied your request. The Plan says this chiropractor is out-of-network with the Plan and you can be treated 
within the Plan network. 
 
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 
chiropractic care to be provided by an out-of-network (OON) provider.