Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network medical center. 
 
You asked the Plan to pre-approve these services. You say that the doctor is a network provider but does not 
work out of a network facility. The Plan denied your request. The Plan says the services are available at a 
network facility. 
 
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 file shows that the Plan 
confirmed the network doctor has privileges at a network medical center and can provide your procedure at this network facility. 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 a referral to an out-of-network medical center.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the wig (A9282) and unlisted special service, 
procedure or report, cap (99199) purchased September 14, 2023. 
 
You asked the Plan to reimburse you for the wig and cap. You say that you are appealing the denial as you 
needed the scalp prosthesis due to chemo treatment cancer. The Plan denied your request. The Plan says the 
items is not a covered benefit and was purchased from a provider who does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. The rules also say that Medicare may pay for items which either meet 
the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these 
same rules. 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Also, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to reimburse you for the wig 
(A9282) and unlisted special service, procedure or report, cap (99199) purchased September 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
August 22, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you were told at 
check in that you did not owe a copayment. Therefore, you feel you should not have to pay one. 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 $90 
copayment for emergency services. 
 
You have been asked to pay a $90 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency 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 an 
emergency room (ER) visit provided on August 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization inpatient care provided from December 12, 
2022, to December 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for post-stabilization inpatient care. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for OON services 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that plans do not have to pay for non-plan care except for 
emergencies, out-of-area urgently needed care, post-stabilization care and pre-approved care.   
 
The record shows that the enrollee was stable for transfer as of December 12, 2022, at 2:20 pm. Once the 
enrollee was deemed stable for transfer, the emergency ended. This means that post-stabilization inpatient care 
was not provided in an emergency. The inpatient care also did not involve out-of-area urgent care services and 
it was not pre-approved. Therefore, we decided that the Plan does not have to pay for post-stabilization 
inpatient care provided from December 12, 2022, to December 15, 2022, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93243 rendered on June 30, 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 there is a more appropriate code for electrocardiographic services for less than 48 hours. 
 
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 93243 is ""External electrocardiographic recording for 
more than 48 hours up to 7 days by continuous rhythm recording and storage; scanning analysis with report." 
 
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 procedure report describes 
recording 1 day; 23 hours and 56 minutes, which equals 47 hours and 56 minutes. In this case, there would be a more specific procedure code to support the service reported. 
 
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 code 93243 rendered on June 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies billed with 
code A4239 for August 13, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services exceed the benefit limit. 
 
The Plan must follow Medicare rules. The rules say that up to a maximum of three (3) months, ninety (90) days 
of the supply allowance may be billed for code A4238 or A4239 at a time and suppliers may not dispense more 
than a ninety (90) day supply.  
 
We looked at the file and Medicare rules. The file shows that one month of supplies billed with code A4239 
was dispensed to the enrollee on August 6, 2023 by a different provider. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the continuous glucose monitor (CGM) supplies billed with code A4239 for August 13, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 31, 
2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you had reached your 
MOOP 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 a $25 
copayment for services from a specialist.  
 The record shows you had not met your MOOP amount prior to this service. You have been asked to pay a $25 
copayment for a specialist office visit. This item/service falls within the physician/practitioner services, 
including doctors office visits 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 a 
specialist office visit provided on July 31, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from July 10, 2023, to August 8, 2023. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says that the admission date on the claim does not match the NOA. 
 
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, we find that the admission date on the claim submitted to the Plan 
matches the admission date on the NOA provided in the case record. It is the Plan's responsibility to support its 
denial with evidence. In this case, the Plan's denial is not supported, so we must find in your favor. Therefore, 
we decided that the Plan has to pay for home health services provided from July 10, 2023, to August 8, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the walking boot and the podiatry office 
visit provided on January 14, 2022. 
 
You asked the Plan to reduce the cost share for the walking boot and the podiatry office visit. You say that you 
disagree with the cost share. 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 per visit, for Medicare-covered podiatry services. Your contract with the Plan also clearly says that 
you must pay 20% coinsurance for Medicare-covered devices and supplies. 
 
You have been asked to pay $72.84, which is 20% coinsurance of the allowed amount for the walking ($364.20 
allowed amount x 20% = $72.84). This item/service falls within the prosthetic devices and related supplies 
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.  
 
You have also been asked to pay a $40 copayment for the podiatry office visit. This item/service falls within 
the podiatry services supplies benefit category. You have been asked to pay a total of $112.84 ($72.84 
coinsurance + $40 copayment = $112.84). 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 cost share for the walking 
boot and the podiatry office visit provided on January 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 24, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial. The Plan denied your 
request. The Plan says that their original decision to deny payment was correct. 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 an office visit provided on July 24, 2023, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan of the brain.  
 
You asked the Plan to pre-approve the PET scan. You say that the requested imaging is necessary to help 
determine future treatment. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the enrollee is noted to have a 
cognitive impairment. However, they are only suspected of having either AD or vascular dementia (per the 
records provided for review). There was no indication that the enrollee has/had FTD or that they meet 
diagnostic criteria for both AD and FTD as required by the NCD for coverage of the requested imaging. The requested imaging study cannot be considered medically 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan of the brain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673). 
 
You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for PCDs have not 
been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCDs have not been met. Specifically, the item coded E0675 is not a covered benefit of 
Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of 
peripheral artery disease, regardless of how they are billed on the claim. Since the base item is not covered, 
related supplies are also not covered. Therefore, we decided that the Plan does not have to pay for pneumatic 
compression devices (E0675, E0673).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 20, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was 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 the laboratory services 
provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service May 28, 
2023.  
 
You asked the Plan to pay for procedure code 99232. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99232 is bundled into payment for code 99233. 
 
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 99232 is a column two code to column one code 99233 with a modifier indicator of 0. The column two 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 99232 billed for date of service May 28, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the skilled nursing facility (SNF) stay 
provided on July 28, 2023, to July 31, 2023. 
 
You asked the Plan to waive the coinsurance for the skilled nursing facility (SNF) stay. You say that you did 
not have to pay a coinsurance when you stayed in the skilled nursing facility previously. 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 10% 
coinsurance for skilled nursing facility (SNF) care. 
 
You have been asked to pay 10% coinsurance for the skilled nursing facility (SNF) stay. This item/service falls 
within the skilled nursing facility (SNF) care 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 $356.14 ($3,561.44 allowed amount x 10% 
coinsurance = $356.14) Therefore, we decided that the Plan does not have to waive the coinsurance for the 
skilled nursing facility (SNF) stay provided on July 28, 2023, to July 31, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ankle x-ray provided on August 12, 
2023. 
 
You asked the Plan to waive the copayment for an ankle x-ray. You say that you had been in and out of the 
hospital and urgent care, and took too long to get answers. This is why you should not have to pay the x-ray. 
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 $95 
copayment for emergency services. 
 
You have been asked to pay a $95 copayment for an ankle x-ray. This item/service falls within the emergency 
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 an ankle x-ray provided on 
August 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 26, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services rendered are not a covered benefit. 
 
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.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. 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 pay for the office 
visit. Therefore, we decided that the Plan does not have to pay for the office visit provided on July 26, 2023, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services (99214) provided on May 17, 2023 to 
June 14, 2023. 
 
You asked the Plan to pay for the telehealth services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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 find that CPT code 99214 is not supported in the medical record. Specifically, this code is not covered for 
audio-only telehealth per the CMS List of Telehealth Services for Calendar Year 2023. Based on this 
information, we decided that Medicare rules for coverage of the telehealth services have not been met. 
Therefore, we decided that the Plan does not have to pay for telehealth services (99214) provided on May 17, 
2023 to June 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and related 
accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair and related accessories. You say that the items 
at issue are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage 
for durable medical equipment have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
 
  Records show that a Group 3 power wheelchair and related accessories are being requested for use in a SNF or 
hospital. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair 
(K0861) and related accessories.