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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says IRF care is not medically necessary, and the enrollee's needs can be met at 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 enrollee is medically stable and no acute rehabilitation nursing needs were 
identified or documented. The complexity of the enrollee's needs does not require an acute hospital inpatient 
rehabilitation stay with an interdisciplinary approach to rehabilitative care. The enrollee's needs can be safely 
provided in an alternate and low intensity 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the epidural injection provided on April 03, 
2023. 
 
You asked the Plan to waive the copayment for the epidural injection. You say that you should only have a $75 
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 $200 
copayment for outpatient surgery provided at an outpatient hospital. 
 
You have been asked to pay a $200 copayment for the epidural injection. This item/service falls within the 
outpatient surgery provided at an outpatient hospital 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 records show the injection was provided at an outpatient 
hospital. Therefore, we decided that the Plan does not have to waive the copayment for the epidural injection 
provided on April 03, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pelvic ultrasound provided on March 27, 2023. 
 
You asked the Plan to pay for the pelvic ultrasound. You say that this service does not require authorization. 
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 pelvic ultrasound 
provided on March 27, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic colonoscopy (45378) and 
esophagogastroduodenoscopy (EGD) (43235). 
 
You asked the Plan to pre-approve a diagnostic colonoscopy and EGD. The Plan denied your request. The Plan 
says this request is not medically necessary because the records show the enrollee does not have any signs or 
symptoms of gastroenteral bleeding or abdominal distress. 
 
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 diagnostic colonoscopy and EGD. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found no laboratory studies were provided to support the veracity of the 
stated indication of IDA (iron deficiency anemia) for the EGD/colonoscopy combination testing. Our reviewer found that as such, medical appropriateness and necessity criteria are not met with the documents provided and 
reviewed. 
 
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 diagnostic colonoscopy and EGD have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a diagnostic colonoscopy (45378) and esophagogastroduodenoscopy 
(EGD) (43235).
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 enrollee needs more intensive rehabilitation to 
regain an optimal level of functionality. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0152, G0299) provided on 
March 2, 2022, to March 31, 2022. 
 You asked the Plan to pay for home health services. You say that the claim was denied in error, and you are 
requesting reconsideration. 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 March 2, 2022. The NOA was not received by the Plan until March 9, 
2022. As more than 5 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0151, 
G0152, G0299) provided on March 2, 2022, to March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 11, 2023, billed with 
procedure code 99239. 
 
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 two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that N39.0 has an Excludes1 note in relation to N30.00. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the practitioner services provided have not been met. Therefore, we decided that the Plan does 
not have to pay for practitioner services provided on April 11, 2023, billed with procedure code 99239.
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 just had your leg amputated and need intensive 
rehabilitation so that you can get back on your feet. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary.  
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 copayment for an office visit provided on May 12, 2023. 
 
You asked the Plan to waive the copayment for an office visit. 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 $10 
copayment for physician/practitioner services/primary care provider. 
 
You have been asked to pay a $10 copayment for an office visit. This item/service falls within the 
physician/practitioner services/primary care provider 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 office visit provided on May 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-pneumatic compression controller with sequential 
calibrated gradient pressure (K1024) and a non-pneumatic sequential compression garment, half leg (K1033).  
 
You asked the Plan to pre-approve a non-pneumatic compression device and garment. You say that you 
disagree with the denial. The Plan denied your request. The Plan says neither Medicare nor the plan cover this 
request. Medical studies have not proven this service/item is helpful for the treatment of the enrollee's health 
problem. 
 
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 non-pneumatic compression device 
and garment. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the review indicates that the enrollee has a history of 
chronic venous insufficiency, and lymphedema. She has a non-healing stage 4 wound of her right lower leg. 
The clinical value and effectiveness of non-pneumatic compression controller with garment in the setting of 
lymphedema with a lower extremity wound have not been demonstrated in the literature. The review has 
determined that the items/services at issue in this case are 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 non-pneumatic compression device and garment have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a non-pneumatic compression controller with 
sequential calibrated gradient pressure (K1024) and a non-pneumatic sequential compression garment, half leg 
(K1033).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a heating pad with pump (E0217) provided on January 18, 
2023 to February 6, 2023. 
 
You asked the Plan to pay for the heating pad with pump. You say that this device was medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. This device is non-covered. Based on this information, we decided 
that Medicare rules for coverage of the heating pad with pump have not been met. Therefore, we decided that 
the Plan does not have to pay for a heating pad with pump (E0217) provided on January 18, 2023 to February 
6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 19, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says this provider is out-of-network and authorization was not 
obtained. 
 
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 provided on June 19, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 20, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says this provider is out-of-network and authorization was not 
obtained. 
 
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 provided on April 20, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service March 31, 
2023. 
 
You asked the Plan to pay for procedure code 99223. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is: Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 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 code 99223. Our reviewer says that procedure 
code 99223 does not meet criteria for payment. Our reviewer found that based on the documentation provided, 
there is no history of present illness, and the medical decision making is not of high complexity. 
 
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 code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 billed for date of service March 31, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) of the breast provided on 
April 4, 2022. 
 You asked the Plan to pay for breast MRI. You say that this was medically necessary. The Plan denied your 
request. The Plan says this testing was performed for screening purposes which is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, breast MRI, was requested for screening purposes. Medicare does not cover this 
test for screening purposes. Therefore, we decided that the Plan does not have to pay for magnetic resonance 
imaging (MRI) of the breast provided on April 4, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each emergency room (ER) visit provided 
on April 30, 2023. 
 
You asked the Plan to waive the copayment for each emergency room (ER) visit. You say that you feel you 
should not be responsible for the cost share because you were advised by your physician to go to the ER. 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 $125 
copayment for emergency care.  
You have been asked to pay a $125 copayment for each 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 each 
emergency room (ER) visit provided on April 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of the 
peripheral nerves of the wrist and supplies (K1018, K1019). 
 
You asked the Plan to pre-approve a Cala Trio device. You say that you disagree with the denial. The Plan 
denied your request. The Plan says Medical studies have not proven this service/item is helpful for the 
treatment of the enrollee's health problem. 
 
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 Cala Trio device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided medical records and review of the current peer-reviewed medical literature 
do not document that use of the Cala Trio device has been shown in controlled studies in a Centers for 
Medicare & Medicaid Services (CMS)-approved journal to result in long term health benefits in enrollees with 
essential tremor. 
 
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 Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an external upper limb tremor stimulator of the peripheral nerves of the wrist and 
supplies (K1018, K1019).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and foot x-ray provided on December 23, 
2022, to February 13, 2023. 
 
You asked the Plan to pay for the office visit and foot x-ray. You say that you are requesting reconsideration of 
the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit and foot 
x-ray provided on December 23, 2022, to February 13, 2023.