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

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health 
treatment beyond the date in question of January 2, 2024 forward and could have been treated in a lesser 
restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression. He was being cooperative and compliant while not 
showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker (E0149) and seat attachment 
(E0156). 
 
You asked the Plan to pre-approve a walker and seat attachment. You say that you are larger from the waist 
down and a regular walker is too tight for you.  The Plan denied your request. The Plan says the enrollee does 
not meet the required Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file and Medicare rules. The records show that the enrollee only weight 240 pounds and does 
not meet the weight requirement. Since the criteria for the walker was not met the seat attachment is also 
denied. Based on this information, we decided that Medicare rules for coverage of a walker and seat attachment 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty walker 
(E0149) and seat attachment (E0156).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional hours with Papa Pals. 
 
You asked the Plan to pre-approve the additional hours with Papa Pals. You say that you are very sick and need 
more hours with Papa Pals.  The Plan denied your request. The Plan says the benefit has been exhausted. 
 
The Plan must follow Medicare rules. Medicare generally does not cover In-home support. However, the Plan 
offers an In-home support benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules 
apply in this case. 
 
Though the Plan offers an In-home benefit in excess of Medicare coverage, certain limitations apply. The 
record shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan 
does not have to pre-approve the additional hours with Papa Pals.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the heavy duty, extra wide hospital bed, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds (E0303) and Powered pressure-reducing 
air mattress (E0303). 
 
You asked the Plan to pre-approve the hospital bed and mattress. You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does 
not meet the weigh requirement for heavy duty hospital bed and additional information was requested but was 
not provided.  
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. The records also show that additional information was needed to 
determine the criteria was met for E0277. The Plan made multiple attempts to obtain the additional information 
from the provider without success. The provided records do show however that the enrollee weighs 294 pounds 
and does not meet the weight requirements for the requested hospital bed. Based on this information, we 
decided that Medicare rules for coverage of the hospital bed and mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the heavy duty, extra wide hospital bed, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds (E0303) and Powered pressure-reducing 
air mattress (E0303).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an oral appliance. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested item can be provided by a network provider. 
 
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 
an oral appliance to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuplazid. 
 
You asked the Plan to pre-approve Nuplazid. You say that the enrollee has been doing well on the medication. 
The Plan denied your request. The Plan says that self-administered drugs do not fall under Medicare Part B 
coverage. 
 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 Nuplazid.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a whole house generator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a whole house generator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on April 5, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services rendered was not pre-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 subsequent nursing facility care provided on 
April 5, 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 the physician services provided on April 5, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for these services. You say that the facility is responsible for authorization. The Plan 
denied your request. The Plan says the services were rendered by an out-of-network provider without prior 
authorization. 
 
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 physician services provided on April 5, 2023, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine foot care rendered on December 20, 2022. 
 
You asked the Plan to pay for these services. You say that you were covered for 12 visits. The Plan denied your 
request. The Plan says you exhausted the benefit limit. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails. The contract with the Plan states that you are covered for six visits per year to a 
network specialist for routine foot care. We looked at the file, Medicare rules, and the Plans rules. The records do not show that you have a condition 
for which Medicare covers routine foot care. The services you are asking the Plan to pay for are routine foot 
care services. The file shows that you used all six visits for routine foot care offered by the Plan as of 
September 6, 2022. Further routine foot care is not covered by your supplemental benefit or Medicare. 
Therefore, we decided that the Plan does not have to pay for the routine foot care rendered on December 20, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on September 26, 2023, billed 
with codes 87481, 87500, 87640, 87652, 87798, 87899 and 87900. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one HCPCS/CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. This was a panel test that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on September 26, 2023, billed with codes 87481, 87500, 87640, 87652, 87798, 87899 and 87900.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a breast prosthesis provided on May 05, 
2023. 
 
You asked the Plan to waive the coinsurance for a breast prosthesis. You say that you do not understand the 
cost sharing. 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 in-network prosthetics. 
 
You have been asked to pay 20% coinsurance for a breast prosthesis. This item/service falls within the in-
network prosthetics benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $60.82 ($304.13 allowed amount x 20% = $60.82). Therefore, we decided that 
the Plan does not have to waive the coinsurance for a breast prosthesis provided on May 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 31, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on July 31, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service September 
19, 2023.  
 
You asked the Plan to pay for procedure code A0425. You say that this patient needed transport to a further 
location due to the severity of their condition. 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 when an MUE has an MAI of 1, units in excess of the 
MUE are only payable when reported on a separate claim line with appropriate use of a modifier.   
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 344 units of 
this code, exceeding the MUE. The units in excess of the MUE were not reported on a separate claim line with 
an appropriate modifier as required. Based on this information, we decided that Medicare rules for coverage of 
procedure code A0425 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code A0425 billed for date of service September 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 99053 billed for date of service June 23, 
2023. 
 
You asked the Plan to pay for procedure code 99053. You say that these services were emergently needed and 
billed correctly. The Plan denied your request. The Plan says procedure code 99053 is considered bundled and 
not separately payable.  
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service June 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on August 09, 2023. 
 
You asked the Plan to pay for wound care services. You say that you are requesting reconsideration for 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 wound care services 
provided on August 09, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 30, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on May 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthopantogram (70355) and office visit (99203) 
provided on June 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were referred to this provider for treatment. 
The Plan denied your request. The Plan says these services are not covered benefits under your dental or 
medical plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Additionally, the services you are asking the Plan to pay for involve 
the care, treatment, filling, removal or replacement of teeth or the structures directly supporting teeth. These are 
dental services that are not covered or paid for by Medicare under your medical benefit. Therefore, we decided 
that the Plan does not have to pay for the orthopantogram (70355) and office visit (99203) provided on June 27, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for odontoplasty (D9971) provided on September 14, 2023. 
 
You asked the Plan to pay for odontoplasty. You say that the service was medically necessary. The Plan denied 
your request. The Plan says this service is not a covered benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
odontoplasty (D9971) provided on September 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 provided on March 7, 2023. 
 
You asked the Plan to pay for procedure code 99284. You say that the medical records support the billing of 
procedure code 99284. The Plan denied your request. The Plan says the medical records do not support the 
billing of procedure code 99284. 
 
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 99284 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
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 99284. Our reviewer says that the medical records do not support the billing of procedure code 99284. Our reviewer found the medical records do not 
support a moderate level of complexity for medical decision making. 
 
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 99284 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99284 provided on March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown-porcelain/ceramic (D2740) provided on August 28, 
2023. 
 
You asked the Plan to pay for the crown. You say that you say you are requesting an appeal against this claim. 
You say your provider has enclosed a statement offering a detailed explanation as to the need for replacement 
of the crown. 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 date of service January 21, 2020. Therefore, we decided that the Plan does not have to pay for a crown-porcelain/ceramic (D2740) provided on 
August 28, 2023.