Persius/hicric huggingface dataset:
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 you were independent before hospitalization and 
wishes to return to being independent. The Plan denied your request. The Plan says your records do not show 
that you need an intensive team for your care. Services needed may be provided safely in a lower level of care. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service February 2, 
2023. 
 You asked the Plan to pay for procedure code 93010. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 93010 is bundled into payment for code 93458. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93010 
is a column II code to column I code 93458. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93010 billed for date of service February 2, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each cataract surgery provided on July 28, 
2022, to August 02, 2022. 
 
You asked the Plan to waive the coinsurance for each cataract surgery. You say that you were not told this 
provider was out-of-network. 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 surgery. 
 
You have been asked to pay 50% coinsurance for each cataract surgery. This item/service falls within the out-
of-network outpatient surgery 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 each 
cataract surgery provided on July 28, 2022, to August 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95861 billed for date of service June 28, 
2022.  
 
You asked the Plan to pay for procedure code 95861. You say that you disagree with the Plan's denial. 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 95861 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 95861 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 95861 billed for date of service June 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 25, 2022, to 
November 22, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have provided records and 
the required NOA so that this claim can get paid. The Plan denied your request. The Plan says the claim has not 
been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from October 25, 2022, to 
November 22, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department services (99284, 70480, and 
S5000) provided on April 20, 2022. 
 
You asked the Plan to pay for the emergency department services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says your facility is not a valid 
Medicare provider and you have provided no evidence that you can bill Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that generally, licensed independent freestanding 
emergency departments (EDs) cannot bill Medicare. However, during the COVID-19 Public Health 
Emergency, these providers can become temporary Medicare providers if they meet certain criteria. 
 
In this case, there is no evidence that your facility meets any of the criteria listed above in order to receive 
Medicare payment. There is no evidence that your facility is affiliated with a hospital, and you have provided 
no evidence that you have completed the temporary enrollment process to become a Medicare hospital. As a 
result, payment to your facility cannot be made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ED services have not been met. Therefore, we decided that the Plan does not have to pay for 
the emergency department services (99284, 70480, and S5000) provided on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialist office visit provided on March 13, 2023. 
 
You asked the Plan to pay for the specialist office visit. You say that you were referred to this provider. 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). The records show you were referred to this provider by another OON provider. Therefore, we decided that the Plan does not have to pay for the specialist office visit provided on March 13, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one pontic (D6240) and two retainer crowns  
(D6750 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you would like to clarify that the bridge 
provided in 2020 was for your upper teeth. The requested procedures are for your lower teeth. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on authorization A0230503146694. 
Therefore, we decided that the Plan does not have to pre-approve one pontic (D6240) and two retainer crowns  
(D6750 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on January 19, 2023, 
to February 15, 2023. 
 
You asked the Plan to waive the coinsurance for injections. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for injections. This item/service falls within the Medicare Part B 
prescription drugs 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 allowed amount for the prescription drugs is $4,820.95. You are being asked to pay $964 
($4,820.95 x 20% = $964). Therefore, we decided that the Plan does not have to waive the coinsurance for 
injections provided on January 19, 2023, to February 15, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service provided on October 
28, 2022. 
 
You asked the Plan to waive the copayment for the ambulance service. You say that you had not been properly 
diagnosed. 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 $300 
copayment for ambulance services. 
 
You have been asked to pay a $300 copayment for the ambulance service. This item/service falls 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 
service provided on October 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the diagnostic mammogram services 
provided on January 5, 2023, and January 25, 2023. 
 
You asked the Plan to waive the cost share for the diagnostic mammogram services. You say that you have 
never had to pay for these services before. 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 $750 deductible which applies to outpatient diagnostic tests and 
therapeutic services. Your contract with the Plan also says that you must pay a $20 copayment after meeting 
the deductible for basic imaging services. 
 
 You have been asked to pay a total of $750 towards the deductible. The item or service you asked the Plan to 
waive the cost share for falls within the outpatient diagnostic tests and therapeutic services benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to outpatient diagnostic tests and therapeutic services. This cost sharing is a contractual obligation that 
had not been met at the time the diagnostic mammogram services were received on January 5, 2023, and 
January 25, 2023.  
 
You have also been asked to pay a $20 copayment for the mammogram services provided on January 25, 2023. 
This item/service falls within the outpatient diagnostic tests and therapeutic 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 cost share for the diagnostic mammogram services provided on January 5, 
2023, and January 25, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qulipta Tab 60 mg. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has had exhaustive migraine 
medication trials without improvement. The Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Qulipta Tab 60 mg.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance services and emergency 
room services provided on February 12, 2023. 
 
You asked the Plan to waive the copayments for the ambulance services and emergency room services . You 
say that you had to be transferred by ambulance to another facility. 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 $180 
copayment for ambulance services. Your contract with the Plan also clearly says that you must pay a $95 copayment for each emergency room visit. 
 
You have been asked to pay a $180 copayment for the ambulance service. This item/service falls within the 
ambulance services benefit category. You have also been asked to pay a $95 copayment for each emergency 
room 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 copayments for the ambulance services and emergency room services provided on February 12, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 82248 billed for date of service December 6, 
2022. 
 
You asked the Plan to pay for procedure code 82248. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says payment for code 82248 is 
bundled into payment for code 80076. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 82248 
is a column II code to column I code 80076. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 82248 billed for date of service December 6, 
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 services are medically necessary for 
the enrollee's care. The Plan denied your request. The Plan says the enrollee does not require transfer to a 
LTACH.  
 
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 the record indicates that the enrollee is not in an acute care setting and requires short 
term acute care for wound management. The acute care services in a short-term acute care facility have not 
been denied.  The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on September 20, 2022. 
 
You asked the Plan to pay for the wound care services. You say that you have an exclusive agreement with this 
facility for this service. 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 wound care services 
provided on September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer bench, heavy duty, for tub or toilet with or 
without commode opening. 
 
You asked the Plan to pre-approve a transfer bench. You say that you would like reconsideration because the 
requested transfer bench is medically necessary. The Plan denied your request. The Plan says the requested 
transfer bench is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that transfer benches are not covered 
because they are not primarily medical in nature.  
 
While a transfer bench may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a transfer bench, heavy duty, for tub or 
toilet with or without commode opening.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health care services provided on November 21, 
2022, by an OON provider.  
 
You asked the Plan to pay for the mental health care services. You say that services were provided in good 
faith. The Plan denied your request. The Plan says this service was not authorized. 
 
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 mental health care services provided on 
November 21, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit evaluation provided on January 09, 2023. 
 
You asked the Plan to pay for the home visit evaluation. You say that this service 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 home visit 
evaluation provided on January 09, 2023.