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

 
We decided that the Plan has to issue additional payment of $674 for the private room rate billed for the 
inpatient hospital care provided from June 30, 2022, through July 2, 2022.  
 
You asked the Plan to issue additional payment for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the cost 
sharing has been applied correctly for the private room billed in this case.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has stated that they called the provider who indicated that 
a private room was requested for the inpatient hospital care provided in this case. However, the Plan has not 
provided phone logs or evidence of such to confirm this. Additionally, the Plan has not provided medical 
records in this case to determine if a private room was medically necessary. While you would still be liable for 
the cost sharing that would apply to the inpatient hospital care provided; the Plan has not substantiated their 
denial of the additional charges for the billing of the private room in this case. Therefore, we decided that the 
Plan has to issue additional payment of $674 for the private room rate billed for the inpatient hospital care 
provided from June 30, 2022, through July 2, 2022.   
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eight additional units of procedure code 77300 rendered on 
May 17, 2023. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that while the documentation does support that excess units were provided, there was no specific 
rationale given for why the additional units needed to be performed. 
 
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 77300 is "Basic radiation dosimetry calculation, central 
axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, 
calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when 
prescribed by the treating physician." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee is being planned and 
treated with adaptive radiotherapy. There is documentation of a a replan on the date of service under dispute. 
The records include a check box form that documents that the current plan would decrease coverage below a 
clinically acceptable level and would increase dose to normal tissues to above clinically acceptable levels  
either of which would support an adaptive plan. Radiation records include treatment plan reports and records, 
and documentation of orders and electronic approval of the prescription and plan. The signed plan documents 
the physician approval of the IMRT plan and therefore the monitor unit calculations. This is sufficient to 
document physician involvement in the treatment planning process. From the treatment planning records there 
are 18 beams with 18 beam calculations. Generally the 77300 billing code is considered to be medically 
necessary for each treatment port/gantry angle though a maximum of 10 units of 77300 (based upon 
recommendations by the ACR and ASTRO) are allowed per course. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for eight additional units of procedure code 77300 rendered on May 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on February 
09, 2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the enrollee thinks that the 
claim was denied. 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 $275 
copayment for each Medicare-covered ground ambulance transport. 
 
You have been asked to pay a $275 copayment for ambulance services. This item/service falls within the each 
Medicare-covered ground ambulance transport 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 ambulance services provided on February 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 21, 2023. 
 
You asked the Plan to pay for an office visit. You say that you were not aware that the provider was out-of-
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 an office visit provided 
on February 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that you are requesting 
reconsideration due to medical necessity. The Plan denied your request. The Plan says the enrollee does not 
have a plan or intent to harm himself or anyone else. He is not hearing voices telling you to harm yourself or 
others and he is not aggressive or violent. There are no medical problems reported. The enrollee could be 
treated in a lower level of care. 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 hospital services. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found it was not 
expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or 
others, auditory or visual hallucinations, delusions and was not showing any behavioral issues. It did not appear 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather 
than a lower level of care as he did not have dangerousness to self or others, perceptual disturbance including 
delusions, auditory or visual hallucinations. The health plans denial of inpatient psychiatric services appears 
appropriate. This enrollee did not appear to require inpatient mental health treatment as he was not a danger to 
himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It 
did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose 
of diagnosis. This enrollee was treated under an individualized treatment plan found in the record. It did appear 
that the records were supervised and evaluated by a physician. Based upon review, the records provided for the 
admission of this enrollee does not meet criteria for acute inpatient mental health treatment as this enrollee was 
not shown to be a danger to himself or others, no auditory or visual hallucinations. He is noted to be 
cooperative and compliant with treatment while not showing any aggressive behaviors. 
 
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 hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral epidural injections (62323, 64483). 
 
You asked the Plan to pre-approve injections. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says there is no clinical evidence to support the medical necessity or Medicare 
criteria for the requested injections. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of acute on chronic lower back pain with radiation to the left groin 
and left lower extremity numbness and tingling with prolonged sitting. The enrollee has not cooperated with 
conservative therapy. The July 27, 2023, physical examination shows no associated lower extremity focal 
neurologic impairment. As of July 27, 2023, the enrollee declined a referral for chiropractic care as it was 
previously ineffective. She also declined a physical therapy referral and continues a physician-supervised 
independent exercise program. Therefore, the enrollee does not meet the LCD criteria and the request is 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve sacral epidural injections (62323, 64483).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization of the legs (37229, 37227, 37225). 
 
You asked the Plan to pre-approve revascularization of the legs. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 revascularization of the legs. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found it is not clear that intervention would provide the enrollee with any 
meaningful improvement in walking distance due to his comorbidities and there is no evidence of limb threat. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization of the legs have not been met. Therefore, we decided that the 
Plan does not have to pre-approve revascularization of the legs (37229, 37227, 37225).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an in-network urgent care visit provided 
on November 14, 2022. 
 
You asked the Plan to reduce the copayment for an in-network urgent care visit. You say that you feel this 
service should be $20 because thats what the customer service line told you. 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 $40 
copayment for urgently needed services. 
 
You have been asked to pay a $40 copayment for an in-network urgent care 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 reduce the copayment for an in-
network urgent care visit provided on November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 27, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. 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 subsequent nursing 
facility care provided on March 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve procedure (64624). 
 
You asked the Plan to pre-approve a genicular nerve procedure. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a genicular nerve procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is an experimental/investigational procedure that is the subject of 
ongoing clinical trials to determine its role in the treatment of osteoarthritis of the knee. 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 a genicular nerve procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve procedure (64624).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 25215 rendered on October 7, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found that the 
records do support that CPT 25215: carpectomy, all bones of proximal row was a separate and distinct 
procedure from CPT 25332: arthroplasty of the wrist, with or without interposition, with or without external or 
internal fixation. The description of the procedure cites that given how flat the lunate was it was determined 
that a 4-corner fusion after a scaphoid excision was in all likelihood not a viable option. The proximal began to 
be removed. Care was taken to preserve the volar ligamentous structures and to preserve any cartilage distal to 
the proximal row. The lunate was removed in a piecemeal fashion and attention was turned to the scaphoid. 
Using an osteotome, the scaphoid was able to be split and removed. The triquetrum was removed. Proximal 
row in its entirety was sent to pathology. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 25215 rendered on October 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 12, 2022, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration for the denied 
payment. The Plan denied your request. The Plan says the services were not 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 Plan contract says the enrollees POS benefit only applies to 
non-Medicare covered dental services covered by the Plan. 
 
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 office visit provided on December 12, 2022, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on December 01, 2022. 
 
You asked the Plan to pay for injections. 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 injections provided on 
December 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing provided on March 23, 2023. 
 
You asked the Plan to pay for laboratory drug testing. 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 drug testing 
provided on March 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service from 
January 1, 2023, to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service from January 1, 2023, to January 28, 2023.