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

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 27, 2022, to 
October 1, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that 
inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee was a high-risk elderly frail woman with a number of acute medical issues that 
warranted hospitalization, with an expectation of greater than two midnights, and thus meets criteria for 
inpatient hospitalization. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from September 27, 2022, to October 1, 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 April 13, 2022, by an OON 
provider.  
 You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this 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 record shows you are 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 April 13, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64450 billed for date of service July 27, 
2022.  
 
You asked the Plan to pay for procedure code 64450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 64450 is bundled into payment for code 11104. 
 
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 64450 
is a column II code to column I code 11104 with a modifier indicator of 0. The column II code is therefore not payable. 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 64450 billed for date of service July 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on January 5, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on January 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87086 provided on February 14, 2023. 
 
You asked the Plan to pay for procedure code 87086. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that urine culture services are coverable when billed 
with a covered diagnosis code. You billed the urine culture service in dispute with diagnosis code N31.8. 
Diagnosis code N31.8 is not listed in the controlling Medicare policy as a covered diagnosis for this service. 
Based on this information, we decided that Medicare rules for coverage of code 87086 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 87086 provided on February 14, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
December 28, 2022, to January 1, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you feel that the 
enrollee should not be responsible for the charges. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $175 copayment each day, for days 1-7, per hospital admission. 
 The enrollee has been asked to pay a $700 copayment for the inpatient hospital stay ($175 x 4 days = $700). 
This item/service falls within the inpatient hospital care benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for the inpatient hospital stay provided from December 28, 2022, to January 1, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic facet joint injections.  
 
You asked the Plan to pre-approve the requested injections. You say that it is felt that this treatment should be 
approved.  The Plan denied your request. The Plan says the criteria for this treatment are not met. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint injections may be covered only 
when prior diagnostic injections provided at least 80% pain relief.  
 
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 requested injections. Our reviewer 
says that the requested treatment is not shown to be medically necessary.  Our physician reviewer found the 
enrollee is a 78-year-old male with a history of chronic low back pain. There is no documentation that there 
were two (2) medically reasonable and necessary diagnostic facet joint procedures with each one providing a 
consistent minimum of 80% relief of primary (index) pain prior to the request of the therapeutic facet joint 
injections. As such, the therapeutic injections are not covered.  
 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 requested injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve therapeutic facet joint injections.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 95816 rendered on December 22, 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 billed code is 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 95816 is "Electroencephalogram (EEG); including recording awake and drowsy." 
 
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 supported by the medical records. Our reviewer found that the medical records support than 
EEG was performed on the enrollee to assess the seizure-like activity the enrollee was having. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 95816 rendered on December 22, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 51600, 51729, and 74455 rendered on 
January 14, 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 the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 records do not support that 
CPT 51600, CPT 51729, and CPT 74455 were rendered in this case. The records show that the following 
procedures were rendered: Complex cystometrogram with voiding pressure studies (i.e. bladder voiding pressure) (CPT 51728) Complex Uroflowmetry (CPT 51741) Voiding pressure studies, intra-abdominal (i.e. 
rectal, gastric, intraperitoneal) (CPT 51797) Patch EMG study of urethral sphincter (CPT 51784) Catheterized 
post-void residual (CPT 51701). 
 
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 procedure codes 51600, 51729, and 74455 rendered on January 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an artificial leg to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an artificial. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the necessary item can be obtained in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an artificial leg to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99282 billed for date of service February 4, 
2023. 
 You asked the Plan to pay for procedure code 99282. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99282 is bundled into payment for code 99284. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99282 
is a column II code to column I code 99284. 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 99282 billed for date of service February 4, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services: medical examination and 
evaluation provided on March 2, 2023. 
 
You asked the Plan to pay for ophthalmological services: medical examination and evaluation. You say that the 
services were medically necessary. The Plan denied your request. The Plan says the provider is not a 
participating vision provider. 
 
The contract with the Plan says the Plans vision provider must be used for vision services. 
 
We looked at the file and the Plan's rules. The file shows that the provider is not a participating vision provider. 
Based on this information, we decided that the Plan's rules for coverage of ophthalmological services: medical 
examination and evaluation have not been met. Therefore, we decided that the Plan does not have to pay for 
ophthalmological services: medical examination and evaluation provided on March 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says per Medicare, medical nutrition therapy diet therapy is 
considered reasonable and necessary when you have problems with your kidneys or have diabetes. Based on 
the clinical information provided to us you do not have problems with your kidneys or have diabetes.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on February 08, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time of service the enrollee was residing in an 
assisted living facility. 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 February 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air conditioner (E1399). 
 
You asked the Plan to pre-approve an air conditioner. You say that you are in Texas and the heat is affecting 
your medical conditions, so the air conditioner is needed. The Plan denied your request. The Plan says this item 
is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an air conditioner (E1399).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99285) provided on February 11, 
2023. 
 
You asked the Plan to pay for the emergency room visit. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan under claim number 820230520101490. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice 
on the same date. Based on this information, we decided that the Medicare rules for the emergency room visit 
have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit 
(99285) provided on February 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 20, 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 provided by a provider who has chosen to opt out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided on January 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you need the elevation system 
so you can be more independent. The Plan denied your request. The Plan says a power seat elevation feature 
(E2300) is non-covered because it is not primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve segmental dermabrasion (15781), and adjacent tissue 
transfer or rearrangement of the face (14061). 
 
You asked the Plan to pre-approve the dermabrasion procedure. You say that this treatment is for scaring and 
healing deformities from a previous Mohs resection of large nasal basal cell carcinoma of the nose, cheek and 
lip. The Plan denied your request. The Plan says dermabrasion is not a covered benefit for the enrollee's 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that dermabrasion is considered medically reasonable 
and necessary for the treatment of rhinophyma. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the dermabrasion procedure have not been met. Specifically, the file does not support that this 
procedure is not being requested to treat rhinophyma. Therefore, we decided that the Plan does not have to pre-
approve segmental dermabrasion (15781), and adjacent tissue transfer or rearrangement of the face (14061).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on 
February 1, 2023. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says this 
claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 18, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency department visit provided 
on February 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm monitor. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence that the loop monitor results will change management. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke, 
or any other apparent indication for this monitor. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of a subcutaneous cardiac rhythm monitor.