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

 
We decided that the Plan does not have to pre-approve right sided sacroiliac radiofrequency ablation. 
 
You asked the Plan to pre-approve right sided sacroiliac radiofrequency ablation. You say that your doctor 
recommended this procedure because you have had this procedure done multiple times and it has helped 
greatly. The Plan denied your request. The Plan says right sided sacroiliac radiofrequency ablation is 
experimental and investigational.  
 
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 right sided sacroiliac radiofrequency 
ablation. Our reviewer says that the requested right sided sacroiliac radiofrequency ablation.is not considered 
medically reasonable and necessary. Our physician reviewer found that you have right sided sacroiliitis. You 
have a past history of scoliosis and you are taking Mobic and Gabapentin for pain. You have had physical therapy and doing a home exercise program. You had a prior radiofrequency ablation of the S1 root, which 
gave you pain relief for 1.5 years. Sacroiliac radiofrequency ablation is considered experimental therapy 
because of the wide variation in efficacy as reported in the literature. Therefore, the request is deemed not 
medically reasonable and 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 right sided sacroiliac radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve right sided sacroiliac radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for each urgent care office visit provided 
from February 7, 2023, to February 14, 2023. 
 
You asked the Plan to increase the reimbursement for each urgent care office visit. You say that you did not 
receive an explanation as to why you were not reimbursed tomorrow. 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 $110 
copayment for urgently needed services received outside the United States.  
 
 The records show you were reimbursed the correct amount. You have been reimbursed the allowed amount 
minus the copayment for each date of service. You have been asked to pay up to a $110 copayment for each 
urgent care office visit. This item/service falls within the urgently needed 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 increase the reimbursement for each urgent care office visit provided from February 7, 2023, 
to February 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH services. 
The Plan denied your request. The Plan says the LTACH services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. Given there are offered alternatives, 
LTACH is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service June 13, 
2023. 
 You asked the Plan to pay for procedure code 93010. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 93010 is bundled into 
payment for code 93459. 
 
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 93459. 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 June 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment purchased on March 21, 2023, and June 6, 
2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that you obtained oxygen concentrator from 
previous in-network provider and returned the rented item back. You also say that you then purchased one on 
your own behalf with an out-of-network provider who does not participate with Medicare. The Plan denied 
your request. The Plan says the purchased oxygen equipment is not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. Therefore, we decided that the Plan does not have to pay for oxygen equipment 
purchased on March 21, 2023, and June 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Part B drugs, medical supplies and 
outpatient surgery on May 09, 2023.  
 
You asked the Plan to waive the cost share for Part B drugs, medical supplies and outpatient surgery. You say 
that you want to appeal the amount being charged. 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 20% 
coinsurance for each Medicare-covered Part B drug. You must pay a 20% coinsurance for each Medicare-
covered medical supply. You must pay $300 copayment for each Medicare-covered outpatient hospital service, 
including observation, outpatient surgery or procedure. The following amount were billed; 
 
The allowed amount of $45.54 x 20% = $9.11. 
The allowed amount of $108.54 x 20% = $21.71. 
The allowed amount of $1.37 x 20% = $0.27. 
The allowed amount of $3.30 x 20% = $0.66. 
The allowed amount of $16.05 x 20% = $3.21. 
The allowed amount of $32.79 x 20% = $6.56. 
The allowed amount of $13.32 x 20% = $2.66. 
The allowed amount of $2.79 x 20% = $0.56. 
The allowed amount of $1,295.16 x 20% = $259.03. 
The allowed amount of $990.44 x 20% = $198.09. 
The allowed amount of $377.78 x 20% = $75.56. 
The allowed amount of $491.39 x 20% = $98.28. 
The allowed amount of $29.11 x 20% = $5.82. 
The allowed amount of $12.82 x 20% = $2.56. 
The allowed amount of $3.30 x 20% = $0.66. 
The allowed amount of $3.30 x 20% = $0.66. 
The allowed amount of $40.05 x 20% = $8.01. 
The allowed amount of $10.40 x 20% = $2.08. 
The allowed amount of $6.24 x 20% = $1.25. 
The allowed amount of $2.31 x 20% = $0.46. 
 
For all services it's, $9.11 + $21.71 + $0.27 + $0.66 + $3.21 + $6.56 + $2.66 + $0.56 + $259.03 + $198.09 + 
$75.56 + 98.28 + $5.82 + $2.56 + $0.66 + $0.66 + $8.01 + $2.08 + $1.25 + $0.46 + $300 = $997.20. Therefore, 
results in total cost sharing amount of $997.20 
 
You have been asked to pay a 20% coinsurance for Part B drugs, a 20% coinsurance for medical supplies and a 
$300 copayment outpatient surgery. This item/service falls within the Medicare Part B prescription drugs, 
outpatient diagnostic tests and therapeutic services and supplies and outpatient hospital 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 Part B drugs, medical supplies and outpatient 
surgery on May 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on June 09, 2023. 
 
You asked the Plan to pay for hospital outpatient clinic visit. You say that the 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 hospital outpatient clinic 
visit provided on June 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 11, 2023. 
 
You asked the Plan to pay for the office visit. You say that this provider was the only one available to provide 
services. 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 provided 
on May 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each diabetic shoe insert provided on May 
22, 2023. 
 
You asked the Plan to waive the coinsurance for each diabetic shoe insert. You say that you received the 
incorrect inserts and you should not have to pay. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for each diabetic shoe insert. This item/service falls within the 
durable medical equipment and related supplies 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 amount you owe for each insert is $30.88 ($154.41 allowed 
amount x 20% = $30.88). The total amount you owe is $61.76 ($30.88 coinsurance x 2 items = $61.76). 
Therefore, we decided that the Plan does not have to waive the coinsurance for each diabetic shoe insert 
provided on May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 21, 2023. 
 
You asked the Plan to pay for laboratory 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 laboratory services 
provided on June 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77063 and 77067 billed for date of service 
July 12, 2023. 
 You asked the Plan to pay for procedure codes 77063 and 77067. You say that these services were coded 
appropriately. The Plan denied your request. The Plan says payment for codes 77063 and 77067 is bundled into 
payment for code 77065. 
 
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 codes 
77063 and 77067 are column II codes to column I code 77065. 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 codes 77063 and 77067 billed for 
date of service July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218) provided 
April 13, 2023, through May 4, 2023. 
 
You asked the Plan to pay for the item. You say that the service was medically necessary. The Plan denied your 
request. The Plan says the service is not covered Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Review of the file shows that 
the enrollee was provided the fluid circulating cold pad with pump (E0218) provided April 13, 2023, through 
May 4, 2023. The rules say that a fluid circulating cold pad with pump (E0218) will be denied as not 
reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the item 
have not been met. Therefore, we decided that the Plan does not have to pay for the fluid circulating cold pad 
with pump (E0218) provided April 13, 2023, through May 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on December 6, 
2022, to December 22, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the billed DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code J96.01. We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was 
correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the use of diagnosis code J96.01 is not supported by the records provided. Our physician 
reviewer found that the enrollee presented with shortness of breath. She was found to have anemia and a 
urinary tract infection. There is no evidence that the enrollee had acute respiratory failure. As such, the billing 
of J96.01 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on December 6, 2022, to December 22, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (AWV) (G0439) provided on June 
12, 2023. 
 
You asked the Plan to pay for the AWV. You say that your previous visit was for a shoulder issue that you 
were having. You also say that this is the only routine physical that you have had this calendar year. The Plan 
denied your request. The Plan says that the benefit for this service has been exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
 
 
 
 
 Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for the annual wellness visit (AWV) (G0439) 
provided on June 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Nurtec ODT tablet. 
 
You asked the Plan to pre-approve Nurtec ODT. You say that the requested drug is a medical necessity for the 
enrollee. 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Nurtec ODT 
tablet.  
 
Benefits for Nurtec ODT 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 pay for emergency department services (procedure code 99284) 
provided on April 5, 2023. 
 
You asked the Plan to pay for emergency department services. You say that the CPT 99284 is appropriate 
based on the level of service required. The Plan denied your request. The Plan says the CPT 99283 is more 
appropriate for the services rendered. 
 
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 emergency department services. Our reviewer says that the 
records do not support the services at issue in this case. Our reviewer found that the documentation contains 
history and physical examination. The enrollee's problem appears to be simple/uncomplicated. The complexity 
of data was limited and required no consideration of multiple diagnoses. Therefore, the documentation 
submitted does not support that the provider performed a moderate level of 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 emergency department services have not been met. Therefore, we decided that 
the Plan does not have to pay for emergency department services (procedure code 99284) provided on April 5, 
2023.
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 meets Medicare criteria and will benefit 
from acute inpatient rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your 
request. The Plan says the request 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 the complexity of the enrollees nursing, medical and rehabilitation needs require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Given the complexity of 
the enrollee's medical conditions, they would benefit from physician oversight and rehabilitation nursing for 
post-operative wound care. The enrollee's medical and rehabilitation needs require the intensive 
interdisciplinary approach provided on acute inpatient rehabilitation. The enrollee requires treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program at least three hours a day and five days a week, or 15 hours over seven consecutive days. As 
of November 2, 2023 the enrollee required minimal assistance with bed mobility, and supervision with sitting 
and standing. The enrollee is non-ambulatory and noted to have 4/5 motor strength. The enrollee has had a 
significant decline from their baseline level of function and would benefit from the intensity of therapies 
provided on acute inpatient rehabilitation. The enrollee can also be evaluated by prosthetics given their 
transfemoral amputation to see if they are a candidate for a prosthesis. Therefore, the acute inpatient 
rehabilitation admission is 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 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.