Persius/hicric huggingface dataset:
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 has a medically complex 
situation with features such as multiple co-morbidities that will require ongoing acute care with complex 
nursing care for a prolonged period. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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 waive the coinsurance for a continuous positive airway pressure 
(CPAP) device provided on February 06, 2023, to March 06, 2023. 
 
You asked the Plan to waive the coinsurance for a continuous positive airway pressure (CPAP) device. You say 
that you have had this machine for 5 years. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare oxygen equipment. 
 
You have been asked to pay 20% coinsurance for a continuous positive airway pressure (CPAP) device. This 
item/service falls within the Medicare oxygen equipment 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 $18.45 ($92.28 allowed 
amount x 20% = $18.45 rounded down). Therefore, we decided that the Plan does not have to waive the 
coinsurance for a continuous positive airway pressure (CPAP) device provided on February 06, 2023, to March 
06, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 03, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the 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 laboratory services 
provided on May 03, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intrauterine device (IUD) (58300) provided on March 22, 
2023. 
 
You asked the Plan to pay for the IUD. You say that this was medically necessary for the enrollee's condition. 
The Plan denied your request. The Plan says procedure code 58300 has a Status Code of N and is therefore a 
non-covered service. 
 
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 58300 has a status indicator of N on the Physician Fee Schedule. This means that 
the service represented by procedure code 58300 is not payable. Therefore, we decided that the Plan does not 
have to pay for the intrauterine device (IUD) (58300) provided on March 22, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on 
December 08, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. 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 $150 
copayment for outpatient surgery/each covered surgery in anambulatory surgical center. 
 
You have been asked to pay a $150 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/each covered surgery in anambulatory surgical center 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 outpatient surgery provided on December 08, 2022.
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 services are medically necessary for the enrollee 
until they are able to transport on their own. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for admission to an IRF.  
 
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 deconditioned chronically and had a decline during their acute hospital 
stay. The enrollee does not have complicated or intensive rehabilitation needs. The enrollee does not require 
24-hour rehabilitation nursing or frequent physiatry follow up. The services cannot be approved at this time.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), x-rays-complete 
series (D0210), adjunctive pre-diagnostic test (D0431), localized delivery of antimicrobial agents (D4381), 
drugs or medicaments (D9630), periodontal scaling and root planing (D4342), and gingival irrigation (D4921) 
provided on July 19, 2022 and August 1, 2022. 
 
 You asked the Plan to pay for the dental services. You say that you tripped and fell flat on your face on the 
concrete which caused your six bottom teeth to be damaged. You say you decided to have a dentist remove 
these six teeth and replace them with a false plate. The Plan denied your request. The Plan says your benefit for 
the comprehensive oral evaluation and the complete series intraoral x-rays has already been exhausted. The 
Plan says the dental benefit does not cover excluded services, even if you receive the services at an emergency 
facility. 
 
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 you received a comprehensive oral evaluation and x-rays on date of service July 11, 2022 which 
exhausted your benefit for these services. In addition, adjunctive pre-diagnostic test, localized delivery of 
antimicrobial agents, drugs or medicaments, periodontal scaling and root planing, and gingival irrigation are 
not covered expenses under the plan. Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation (D0150), x-rays-complete series (D0210), adjunctive pre-diagnostic test 
(D0431), localized delivery of antimicrobial agents (D4381), drugs or medicaments (D9630), periodontal 
scaling and root planing (D4342), and gingival irrigation (D4921) provided on July 19, 2022 and August 1, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure device provided on 
April 01, 2023, to May 01, 2023. 
 
You asked the Plan to pay for a continuous positive airway pressure device. 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 a continuous positive 
airway pressure device provided on April 01, 2023, to May 01, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you were not aware that insurance would no longer 
cover your stay and missed the deadline to appeal, and you are still bed bound due to a broken leg and cannot 
put weight on the foot. The Plan denied your request. The Plan says your records show that you refuse to use 
commode, request incontinence briefs, and has poor motivation with therapy. You do not meet skilled nursing 
criteria for medical issues. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerendia. 
 
You asked the Plan to pre-approve the medication. You say that Kerendia is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Kerendia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on June 15, 2023. 
 
You asked the Plan to pay for the x-ray. You say that you weren't aware the x-ray is only covered once in 36 
months. You say it was the dentist's decision, and it was medically necessary. 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 August 15, 2021. 
Therefore, we decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on June 15, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from 
April 25, 2023, to April 27, 2023.  
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you should only have 
a $320 copayment for this service. 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 $320 
copayment per day, for days 1 to 5 and a $0 copayment per day, for days 6 to 90 of in-network hospital care. 
 
 You have been asked to pay a $320 copayment per day, for days 1 to 2 of the inpatient hospital stay. You have 
been asked to pay a total of $640 ($320 copayment x 2 days = $640). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital stay 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 reduce the copayment for the inpatient hospital stay provided from April 25, 2023, to April 27, 
2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mental health visit provided on March 17, 2023. 
 
You asked the Plan to pay for a mental health visit. 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 a mental health visit 
provided on March 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87502 and 87798 for date of service 
November 30, 2022. 
 
You asked the Plan to pay for procedure codes 87502 and 87798. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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 87502 is infectious agent detection by nucleic acid (DNA 
or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when 
performed, and multiplex amplified probe technique, first 2 types or sub-types. 
The CPT Code Manual definition of code 87798 is infectious agent detection by nucleic acid (DNA or RNA), 
not otherwise specified; amplified probe technique, each organism.  
We find that CPT codes 87502 and 87798 are not supported in the medical record. Specifically, the submitted 
medical records do not indicate that infectious agent detection by nucleic acid (DNA or RNA); influenza virus, 
for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex 
amplified probe technique, first 2 types or subtypes was performed. There is a more appropriate code to be 
billed for the services rendered. The submitted medical records include the cytology report; however, the 
cytology report doesn't include a complete description of the unlisted code billed; therefore, code 87798 cannot 
be verified. Based on this information, we decided that Medicare rules for coverage of procedure codes 87502 
and 87798 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
87502 and 87798 for date of service November 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neurological or neuromuscular diagnostic procedures 
(95999 x3) provided on May 6, 2022. 
 
You asked the Plan to pay for the neurological or neuromuscular diagnostic procedures. You say that you 
would like this claim to be reprocessed as you have submitted proper proof and documentation based on the 
revised filing deadlines. The Plan denied your request. The Plan says payment is not allowed for this claim 
because it was submitted after timely filing limitations. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 The record shows that a claim for the neurological or neuromuscular diagnostic procedures was not filed until 
May 18, 2023. This means that more than one calendar year from the date of service had passed before a claim 
was filed. Therefore, we decided that the Plan does not have to pay for the neurological or neuromuscular 
diagnostic procedures (95999 x3) provided on May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 19, 2022. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial with supporting 
documentation. 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 October 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 1, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the service 
should be paid because you thought you were having a heart attack. You also say that the ambulance did not 
take you to the emergency room, and it does not state in the Evidence of Coverage that ambulance with no 
transport is not covered. The Plan denied your request. The Plan says since there was no transport, the 
ambulance service is not covered, and the claim is not payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 1, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on April 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 99232 billed for date of service April 15, 
2023 to April 16, 2023.  
 
You asked the Plan to pay for procedure code 99232. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99232 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99232 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99232 billed for date of service April 15, 2023 to April 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for flow cytometry procedures; 16 or more markers provided on 
September 30, 2022. 
 
You asked the Plan to pay for flow cytometry procedures; 16 or more markers. The Plan denied your request. 
The Plan says flow cytometry procedures; 16 or more markers is not a Medicare benefit for the diagnoses listed 
on the claim and are done for screening purposes.  
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. The file shows that the diagnoses billed are not a covered benefit per 
the Medicare LCA. Based on this information, we decided that Medicare rules for coverage of flow cytometry 
procedures; 16 or more markers have not been met. Therefore, we decided that the Plan does not have to pay 
for flow cytometry procedures; 16 or more markers provided on September 30, 2022.