Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 23, 2023. 
 
You asked the Plan to pay for lab services. You say that you cannot afford to let these claims go unpaid. 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 lab services provided on 
January 23, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation (A0428, A0425) returning from 
dialysis treatment on November 14, 2022. 
 
You asked the Plan to pay for ambulance transportation. 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 certain medical items, supplies, and services 
furnished to inpatients are covered by the prospective payment rate or reimbursed as reasonable costs under 
Part A to hospitals excluded from the PPS. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance transportation have not been met. Specifically, the services at issue are transportation 
services provided to an enrollee admitted as an inpatient during the date of service at issue. Payment for these 
services is included in payment to the hospital for the enrollee's admission and stay. Therefore, we decided that 
the Plan does not have to pay for ambulance transportation (A0428, A0425) returning from dialysis treatment 
on November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on August 31, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that this was medically necessary and should 
be covered. 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 physical therapy 
services provided on August 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service October 20, 
2022.  
 You asked the Plan to pay for procedure code 76642. You say that this should be paid for. 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 claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit, and debridement of nails provided on January 
31, 2023. 
 
You asked the Plan to pay for a home visit, and debridement of nails. You say that these services were 
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 a home visit, and 
debridement of nails provided on January 31, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service January 16, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, this code was billed with 
primary diagnosis code F09 (Unspecified mental disorder due to known physiological condition). This 
diagnosis code has a "code first" note meaning the underlying condition be sequenced first followed by the 
manifestation. Diagnosis F09 is not valid as a primary diagnosis. The claim is not payable as billed. Based on 
this information, we decided that Medicare rules for coverage of procedure code 99285 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99285 for date of service January 
16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services (99441) provided on November 10, 2022. 
 
You asked the Plan to pay for the telehealth services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 99441 is not supported in the medical record. Specifically, the claim was not billed with 
the required modifier 95 for telehealth services. Based on this information, we decided that Medicare rules for 
coverage of the telehealth services have not been met. Therefore, we decided that the Plan does not have to pay 
for telehealth services (99441) provided on November 10, 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 does met the admission 
criteria and the enrollee's ongoing care requires an LTACH level of care. The Plan denied your request. The 
Plan says the LTACH is medically necessary, and the enrollee's needs can be met at a lower level of care such 
as a skilled nursing 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the current acute care 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion exercise device for use 
other than knee (E0936). 
 
You asked the Plan to pre-approve a continuous passive motion exercise device. You say that you believe the 
machine is as important to the shoulder as it is for the knee. You also say without the machine you will not 
have function of your right arm and you are right-handed. The Plan denied your request. The Plan says per 
Medicare guidelines, the requested device for use other than the knee is not approved. 
 
The Plan must follow Medicare rules. Medicare rules say that continuous passive motion devices are devices 
covered for patients who have received a total knee replacement. 
 
We looked at the file and Medicare rules. The record shows that this device is not being requested for use on 
the knee, but for use on your shoulder. Based on this information, we decided that Medicare rules for coverage 
of a continuous passive motion exercise device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous passive motion exercise device for use other than knee (E0936).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on September 12, 2022. 
 
You asked the Plan to pay for a new patient office visit. You say that the services rendered were 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 a new patient office visit 
provided on September 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 home health occupational therapy visits and 9 skilled 
nursing visits. 
 You asked the Plan to pre-approve home health services. You say that the enrollee needs the therapy and 
skilled nursing. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
documentation does not support that the enrollee requires additional skilled nursing services or skilled 
rehabilitation services to provide treatment that is medically necessary. The enrollee does not require additional 
skilled nursing or rehabilitation services to effectively provide treatment, care, and/or services in order to 
improve the enrollees condition, perform a maintenance program to maintain the enrollees condition and/or 
prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic 
medical problems or hospitalizations. The requested home health services are not medically 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 5 home health occupational therapy visits and 9 skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lightweight wheelchair provided on November 21, 2022. 
 
You asked the Plan to pay for a lightweight wheelchair. You say that this item 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 a lightweight wheelchair 
provided on November 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the acute inpatient psychiatric hospital care 
provided from February 17, 2023, through February 24, 2023. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 $390 
copayment per day, for days 1 to 5 and a $0 copayment per day, for days 6 to 90, for acute inpatient mental 
health care.  
 
  
 
 
You have been asked to pay $1,170 ($390 copayment x 3 days) for the acute inpatient psychiatric hospital care 
provided. 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 acute inpatient psychiatric hospital care 
provided from February 17, 2023, through February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on December 21, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that you think that these services should be 
covered. 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 nursing facility care 
provided on December 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on 
March 01, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that this was requested 
after a faulty screening mammogram. 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 $50 
copayment for in-network diagnostic tests, including diagnostic mammograms. 
 
You have been asked to pay a $50 copayment for the diagnostic mammogram. This item/service falls within 
the in-network diagnostic tests, including diagnostic mammograms 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 diagnostic mammogram provided on March 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on October 11, 2022. 
 
You asked the Plan to pay for office visit. You say that you say the services were in-network. 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 office visit provided on 
October 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service December 1, 
2022. 
 You asked the Plan to pay for procedure code 88377. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 88377 is bundled into payment for code 81342. 
 
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 88377 
is a column II code to column I code 81342. 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 88377 billed for date of service December 1, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, molar root canal, post and core, and 
a crown (D0140, D3330, D2954, D2750) provided on February 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. Coverage for the prefabricated post and core denied correctly as they do not fall within 
your Dental benefits. 
 
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 date of service December 01, 2022 
(D0140), January 06, 2022 (D3330), January 11, 2022 (D2750). Therefore, we decided that the Plan does not 
have to pay for a limited oral evaluation, molar root canal, post and core, and a crown (D0140, D3330, D2954, 
D2750) provided on February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the arthrocentesis and drug injection 
provided on March 30, 2023. 
 
You asked the Plan to waive the cost share for the arthrocentesis and drug injection. You say that you were not 
aware you were on this Plan and did not know about the deductible. 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 surgery. Your contract 
with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B drugs. 
 
You have been asked to pay $62.70 towards the deductible. The item or service you asked the Plan to waive the 
cost share for falls within the outpatient surgery benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient surgery. This cost 
sharing is a contractual obligation that had not been met at the time the arthrocentesis and drug injection was 
received on March 30, 2023.  
 
You have also been asked to pay $0.85, which is 20% coinsurance of the allowed amount for the drug injection 
($4.24 allowed amount x 20% coinsurance = $0.85). You have been asked to pay a total of $63.55 for the 
arthrocentesis and drug injection ($62.70 deductible + $0.85 coinsurance = $63.55). 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 arthrocentesis and drug injection provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services from an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says dental services from an out-of-network 
provider are not covered by your supplemental benefits. 
 
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. 
 
 You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve dental 
services from an out-of-network provider.