Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 25, 2023. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says 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 says that the Plan has also determined that these services are not urgent or emergent, 
nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on May 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Aurora Spine ZIP Interspinous Fixation device to 
L4-L5. 
 
You asked the Plan to pre-approve an Aurora Spine ZIP Interspinous Fixation device. You say that this would 
help the enrollee with their back pain. The Plan denied your request. The Plan says medical studies have not 
proven this item for the treatment of the enrollee's condition. 
 
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 an Aurora Spine ZIP Interspinous Fixation device. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found there were no diagnostic testing studies provided for 
review to corroborate lumbar pathology. There were also no objective findings noted of the lumbar spine. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Aurora Spine ZIP Interspinous Fixation device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an Aurora Spine ZIP Interspinous Fixation 
device to L4-L5.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for PT services provided from April 21, 2023, 
and May 3, 2023. 
 
You asked the Plan to waive the deductible for PT services. You say that you were told by the Plan that you 
were covered for the PT services. 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. Your 
contract with the Plan says that there is a $525 deductible which applies to outpatient rehabilitation services.  
 
The item or service you asked the Plan to waive the copayment for falls within the outpatient rehabilitation 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $525 deductible which applies to outpatient rehabilitation services. This cost sharing is a contractual 
obligation that had not been met at the time PT services was received on April 21, 2023, to May 3, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for PT services provided from April 
21, 2023, and May 3, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a sleep study provided on April 13, 2023. 
 
You asked the Plan to waive the coinsurance for a sleep study. You say that you disagree with the coinsurance. 
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 outpatient diagnostic tests/sleep study. 
 
You have been asked to pay 20% coinsurance for a sleep study. This item/service falls within the outpatient 
diagnostic tests/sleep study 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 allowed amount for the sleep study is $325. You are being asked to pay $65 ($325 x 20% = $65). Therefore, we decided that the Plan does not have to waive the coinsurance for a sleep 
study provided on April 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee can be treated at a lower level of care. 
 
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.  
Specifically, 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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 95861 rendered on March 24, 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 there is a more appropriate code for these 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 definition of 
code 95861 is "Needle electromyography; 2 extremities with or without related paraspinal areas." 
 
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 in this case, the use of the term 
sEMG relates to spontaneous electromyography, not surface electromyography. tEMG refers to "triggered." 
Intraoperative neuromonitoring recording of EMG activity is otherwise done with needles to record the 
responses, rather than surface electrodes. In as much it can be said that the CPT code submitted was otherwise 
appropriate. 
 
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 95861 rendered on March 24, 2023.  
 
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 waive the copayment for the specialist office visit provided on June 
20, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you could not get an 
appointment in the 10 day post-operative period. 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 $45 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $45 copayment for the specialist office visit. This item/service falls within the 
specialist physician/practitioner 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 the specialist office visit provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management provided on May 31, 2023. 
 
You asked the Plan to pay for the chronic care management. You say that the services were provided by your 
primary care provider. 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 chronic care 
management provided on May 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injection provided on March 03, 
2023. 
 
You asked the Plan to waive the coinsurance for the drug injection. You say that the allowed amount is too 
high, which results in a higher coinsurance amount. 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 Part B drugs. 
 
You have been asked to pay 20% coinsurance for the drug injection. This item/service falls within the 
Medicare Part B drugs 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 $951.91 ($4,759.56 allowed amount x 20% coinsurance = $951.91). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the drug injection provided on 
March 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter (K0800). 
 
You asked the Plan to pre-approve a scooter. You say that you cannot walk more than a few feet. You also say 
that you need this scooter to leave your home so you can be mobile outside of your home. The Plan denied 
your request. The Plan says this request is not medically necessary because your records do not show you are 
having problems finishing one or more of your Mobility-Related Activities of Daily Living (MRADLs) inside 
the home, that you are unable to use a cane walker or manual wheelchair, or if you can maintain upright 
posture and safely use a scooter. The Plan also says that your appeal request states that you are asking for the 
scooter for use outside the home and Medicare Guidelines state that DME must be for use in the home. 
 
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 pre-approve a scooter (K0800).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on April 24, 2023 by an out-of-network provider. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting reimbursement. The 
Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider.  
 
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. 
 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on April 24, 2023 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on January 27, 2023. 
 
You asked the Plan to pay for the laboratory service. 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 the laboratory service 
provided on January 27, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95937. We decided that the Plan does not have to pay for 99205.  
 
You asked the Plan to pay for procedure codes 95937 and 99205 rendered on May 8, 2023.. You say that this 
should be paid for. The Plan says that the denied codes remain not supported. 
 
We decided that the Plan has to pay for 95937.   
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 95937 is "Neuromuscular 
junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method." 
 
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 for CPT 95937. Our reviewer says that the report does 
indicate that repetitive nerve stimulation (RNS) testing was performed. 
 
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 
95937.  
 
We also decided that the Plan does not have to pay for 99205. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 99205 is "Office or other 
outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate 
history and/or examination and high level of medical decision making. When using time for code selection, 60-
74 minutes of total time is spent on the date of the encounter." 
 
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 for CPT 99205. Our reviewer says that the records do 
not support a medically appropriate history and examination. A history was taken, but in the neurological exam 
portion, some of the details were more scant than they should have been. More specifically, there was mention 
of lower extremity weakness, but no form of grading, which is a standard. The sensory exam also appears to 
have been limited. Additionally, the enrollee presented with many known/straightforward diagnoses. Therefore, 
the level of medical decision making was not high. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99205 have not been met. Therefore, we decided that the Plan does not have to 
pay for 99205. 
 
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 an office visit and a radiologic examination provided on June 
07, 2023. 
 
You asked the Plan to pay for an office visit and a radiologic examination. 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 an office visit and a 
radiologic examination provided on June 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the multi bath chair with tilt 20x20 padded commode 
seat.  
 
You asked the Plan to pre-approve a shower or bath chair. You say that you would like reconsideration because 
the requested multi bath chair with tilt 20x20 padded commode seat is medically necessary. The Plan denied 
your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve the multi bath chair with tilt 20x20 
padded commode seat.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 26, 2022, 
to December 1, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
have billed the services at issue correctly. The Plan denied your request. The Plan says rules for payment at the 
DRG originally billed have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis A41.9, defined as Sepsis, 
unspecified organism. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the services at issue do not meet criteria for 
payment at the DRG originally billed. Our physician reviewer found the provided documentation did not 
sufficiently support the diagnosis code, A41.9 (sepsis), as the Sepsis 3 criteria was not met. There was 
insufficient evidence of organ failure directly related to a dysregulated response to systemic infection.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 26, 2022, to December 1, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost for an MRI provided on May 10, 2023. 
 
You asked the Plan to reduce the cost for an MRI. You say that you met your deductible in March of 2023. 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. Your 
contract with the Plan says that there is a $190 deductible which applies to outpatient diagnostic tests and 20% 
coinsurance for outpatient radiological services will be applied after the deductible has been met.  
 
 
  The item or service you asked the Plan to reduce the cost for falls within the outpatient diagnostic tests benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $190 
deductible which applies to outpatient diagnostic tests. This cost sharing is a contractual obligation that had not 
been met at the time an MRI was received on May 10, 2023. The remaining $135.62 deductible was met after 
the processing of this claim. After the deductible was met the Plan applied $48.20 coinsurance, which is 20% 
of the allowed amount for an MRI ($240.99 allowed x 20% = $48.20). Therefore, we decided that the Plan does 
not have to reduce the cost for an MRI provided on May 10, 2023.