Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223, & 99233 provided on May 24, 2023 
to May 25, 2023. 
 
You asked the Plan to pay for procedure codes 99223, & 99233. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 definitions of codes 99223, & 99233 are initial hospital inpatient or 
observation care, per day, for the evaluation and management of a patient, requiring a medically appropriate 
history and examination and high level of medical decision making OR must meet or exceed 75 minutes 
(99223), and subsequent hospital inpatient or observation care, per day, for the evaluation and management of a 
patient, requiring a medically appropriate history and examination and high level of medical decision making OR must meet or exceed 50 minutes (99233). 
 
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 codes 99223, & 99233. Our reviewer says that the 
records do not support the codes billed. Our reviewer found the documentation provided does not support 
complex decision making, 75 minutes of time or more for the initial evaluation or 50 minutes or more for the 
subsequent evaluation. 
 
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 codes 99223, & 99233 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 99223, & 99233 provided on May 24, 2023 to May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on May 09, 2023. 
 
You asked the Plan to pay for the home visit. You say that the assisted living facility is responsible for 
obtaining authorization. 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 home visit provided 
on May 09, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that the surgical boot / shoe provided on April 10, 2023. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot 
orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulation provided on May 30, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the chiropractic manipulation. You say that you are requesting reconsideration of 
the denied claim. The Plan denied your request. The Plan says the service was 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 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 chiropractic manipulation provided on May 
30, 2023, by an OON provider.
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 
to receive the care needed to return to their prior level of function. 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 does not require the intensity of services provided at an IRF. The 
enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. The enrollees care needs can be met at a lower level of care. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 05, 2023. 
 
You asked the Plan to pay for the office visit. You say that you were not told that prior authorization would be 
needed for the consultation, only the surgery. 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 July 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for massage therapy provided on June 19, 2023. 
 
You asked the Plan to pay for massage therapy. You say that your physical therapist suggested a deep tissue 
massage. The Plan denied your request. The Plan says massage therapy is not covered by Medicare because it 
is considered alternative/complementary therapy unless provided by a licensed physical therapist or 
occupational therapist of therapy treatment.  
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for massage therapy provided on June 19, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services provided on May 7, 
2023. 
 You asked the Plan to pay for the ambulance transportation services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance services are not separately payable 
when the enrollee is inpatient. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee was inpatient for this date 
of service. This means the ambulance services are considered bundled into the payment to the hospital. Based 
on this information, we decided that Medicare rules for coverage of the ambulance transportation services have 
not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation 
services provided on May 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye refractions provided on March 27, 2023. 
 
You asked the Plan to pay for eye refractions. You say that you never had to pay for a refraction previously 
with the Plan. The Plan denied your request. The Plan says it was a medical visit.  
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for eye refractions provided on March 27, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided by an out-of-network 
provider on January 30, 2023. 
 
You asked the Plan to pay for the critical care services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the services rendered was not medically reasonable and 
necessary. 
 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 pay for the critical care services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has a history of hypertension, hyperlipidemia, prediabetes, and 
gastroesophageal reflux disease who presented to the emergency department on January 20, 2023, with flank 
pain after dental extractions. The evaluation revealed creatinine increased to 3.3 with probable benign prostatic 
hyperplasia/urinary retention. The enrollee was evaluated; seen in consultation by nephrology and admitted. 
The enrollee's antihypertensive medications were held and was started on Flomax. The enrollee's condition 
improved, and they were discharged home on February 1, 2023, with primary care physician/nephrology 
outpatient follow-up. 
 
The review indicates that the enrollee required observation level of care services after the emergency room 
evaluation but no critical care services. 
 
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 critical care services have not been met. Therefore, we decided that the Plan 
does not have to pay for the critical care services provided by an out-of-network provider on January 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on April 19, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 14, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not urgent/emergent and are available with Plan 
providers. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
 The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for physician's services provided on July 14, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 17, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. 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 $260 
copayment for ambulance services. 
 
You have been asked to pay a $260 copayment for ambulance services. This item/service falls within the 
ambulance 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 copayment for ambulance services 
provided on March 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing visits (G0299). 
 You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found provided 
records do not document any acute or unstable medical conditions or changes in medication or treatment which 
would necessitate skilled nursing visits. No medical notes from the enrollee's treating physician are provided 
documenting an order or need for skilled nursing services. Records do not document the need for intravenous 
medications, new tube feeding or ostomy care or complex wound care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing visits (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulation provided on June 9, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the chiropractic manipulation. You say that you are requesting reconsideration of 
the denied claim. The Plan denied your request. The Plan says the service was 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 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 chiropractic manipulation provided on June 9, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 23, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on February 23, 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 service is medically necessary. The 
enrollee needs service as soon as possible or their life would be in jeopardy. The Plan denied your request. The 
Plan says this is 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 the enrollee is receiving appropriate care in current acute care setting as provided by 
Health Plan. Documentation does not support that LTACH services are medically appropriate 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 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 the office visit provided on April 26, 2023. 
 
You asked the Plan to pay for the office visit. You say that you did not know the enrollee had this Plan, and 
you are requesting retro authorization. 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 April 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a cystourethroscopy procedure provided 
on July 27, 2023. 
 
You asked the Plan to reduce the copayment for a cystourethroscopy procedure. You say that the procedure did 
not take place at a hospital. 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 $325 
copayment for outpatient hospital services. 
 
You have been asked to pay a $325 copayment for a cystourethroscopy procedure. This item/service falls 
within the 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. The record shows the procedure was rendered at a hospital. Therefore, we 
decided that the Plan does not have to reduce the copayment for a cystourethroscopy procedure provided on 
July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 3, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says it was processed correctly due to the claim not being filed 
until May 10, 2023 without good cause. 
 
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 an office visit was not filed until May 10, 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 an office visit provided on February 3, 2022.