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

 
We decided that the Plan does not have to waive the copayment and pay for an emergency room visit and self-
administered drugs provided from March 10, 2023, to March 11, 2023. 
 
You asked the Plan to waive the copayment and pay for emergency room visit and self-administered drugs. 
You say that this facility should be covered. 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 $95 
copayment for emergency room visit.  
 
You have been asked to pay $95 copayment for emergency room visit. This item/service falls within the 
Emergency 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. Additionally, the rules say that Medicare Part B generally does not pay for self-administered drugs. 
The self-administered drugs requested here are not among the types which are covered by Medicare Part B. 
Therefore, we decided that the Plan does not have to waive the copayment and pay for an emergency room visit 
and self-administered drugs provided from March 10, 2023, to March 11, 2023.  
 
Benefits for emergency room visit and self-administered drugs may be available under Medicare Part D. 
Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal 
rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a liver transplant evaluation. 
 
You asked the Plan to pre-approve the evaluation. The provider says that a transplant evaluation is warranted 
due to the enrollee's significant decompensation and risk of death. The provider also says that the enrollee 
would meet with a multi-disciplinary team to ensure that the comorbidities are not prohibitive to 
transplantation. The Plan denied your request. The Plan says this is not medically 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 pre-approve the evaluation. Our reviewer says that 
the requested transplant evaluation is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the list of indications for liver transplantation includes all the causes of end stage 
liver disease which are irreversible and curable by the procedure. The reviewer found that contraindications to the procedure include severe cardiopulmonary disease, active alcohol and substance abuse, advanced age 
(greater than 65), obesity (body mass index [BMI] greater than 45), and HIUV infection. The documentation 
indicates that the enrollee is over the age of 65, and has diagnoses which include obesity, aortic stenosis and 
diabetes, which could affect the outcome of transplant surgery. Therefore, the reviewer found that the requested 
transplant evaluation is not medically reasonable or 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 evaluation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a liver transplant evaluation.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), expandable 
controller (E2377), and two bracket assemblies (K0108 x2). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, and two bracket 
assemblies. You say that the enrollee is in great need of the requested power chair. You also say the enrollee 
will use the chair for multiple hours per day and it will allow them to maintain their independence with 
mobility and will greatly improve their quality of life. The Plan denied your request. The Plan says that 
although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there 
is not a medical need to control these power options through the joystick. The Plan says the footplate 
accessories coded as K0108 are miscoded. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 electronic connection, harness, 
expandable controller, and two bracket assemblies. Our reviewer says that the requested items/services are 
considered medically reasonable and necessary in this case. Our physician reviewer found the complexity of 
the enrollee's seating and positioning needs necessitates a more complex group 3 power wheelchair base. Our 
reviewer found that the expandable controller with harness and electronic connection are necessary to operate 
the group 3 power wheelchair base and the three power options via a joystick. These components are required 
to operate 3 or more power options on a group 3 power wheelchair. Our physician reviewer also found that the 
bracket assemblies are required for positioning of the enrollee's extremities. 
 
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 electronic connection, harness, expandable controller, and two bracket 
assemblies have been met. Therefore, we decided that the Plan has to pre-approve an electronic connection 
(E2311), harness (E2313), expandable controller (E2377), and two bracket assemblies (K0108 x2).  
 
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 practitioner services provided on August 12, 2022, billed 
with procedure code 95999. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 95999 is unlisted neurological or neuromuscular 
diagnostic procedure. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that it is not appropriate to bill separately 
for train-of-four (TOF) monitoring. The American Medical Association (AMA) has clearly stated that CPT 
code 95937 is not appropriate for this procedure, nor may TOF monitoring be billed with an unlisted code. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on August 12, 2022, billed with procedure code 
95999.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service May 28, 
2023. 
 
You asked the Plan to pay for procedure code 99140. You say that these services were medically necessary, 
and you have provided medical records to support payment. The Plan denied your request. The Plan says 
procedure code 99140 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service May 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic evaluation (D0120) provided on July 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 23, 2023. 
Therefore, we decided that the Plan does not have to pay for a periodic evaluation (D0120) provided on July 
26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
February 23, 2023, through February 24, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient psychiatric hospital care 
provided was not medically necessary.   
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient psychiatric hospital care 
provided from February 23, 2023, through February 24, 2023. Our reviewer says that the acute inpatient 
psychiatric hospital care provided was not medically necessary. Our physician reviewer found that the enrollee 
was admitted for acute inpatient psychiatric hospitalization on February 22, 2023 with Adjustment Disorder 
and Malingering. Based upon the review of the records provided, it was not expected that this enrollee would 
improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual 
hallucinations, or delusions, and was not showing any behavioral issues. It did not appear medically necessary 
and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of 
care as he did not have dangerousness to self or others, perceptual disturbance including delusions, or auditory 
and visual hallucinations. The health plans denial of inpatient psychiatric services appears appropriate. This 
enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others 
and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear 
that the services were reasonably expected to improve the enrollees condition or were for the purpose of a 
diagnosis. It did appear that the records were supervised and evaluated by a physician. Based upon the review 
of the records provided, the enrollee did not meet criteria for coverage of the acute inpatient mental health 
treatment provided as he was not shown to be a danger to himself or others, and did not have auditory or visual 
hallucinations. He was noted to be cooperative and compliant with treatment while not showing any aggressive 
behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient psychiatric hospital care provided from February 23, 2023, through  
February 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
May 5, 2023, through May 8, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient psychiatric hospital care 
provided was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient psychiatric hospital care 
provided from May 5, 2023, through May 8, 2023. Our reviewer says that the acute inpatient psychiatric 
hospital care provided was not medically necessary. Our physician reviewer found that the enrollee was 
admitted for acute inpatient psychiatric hospitalization on April 30, 2023 with Major Depressive Disorder, 
Recurrent, Severe without Psychotic Features. Based upon the review of the records provided, it was not 
expected that this enrollee would improve in a reasonable period of time beyond the dates in question as he was 
not showing any dangerousness to self or others, auditory or visual hallucinations, and was without aggressive 
behaviors while not showing any acute threats of safety. It did not appear medically necessary and reasonable 
to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the 
dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations, or 
abnormal behaviors. The health plans denial of continued inpatient psychiatric services appears appropriate. 
This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as 
he was not a danger to himself or others and did not have any delusions, or auditory and visual hallucinations. 
It did not appear that active treatment was taking place beyond the date in question. It did not appear that the 
services for the dates in question were reasonably expected or medically necessary to improve the enrollees 
condition or were for the purpose of a diagnosis. It appears that the services were supervised and evaluated by a 
physician. Based upon the review of the records provided, this enrollee does not meet the criteria for coverage 
of the acute inpatient mental health treatment beyond the date in question of May 5, 2023 forward and could 
have been treated in a lesser restrictive setting. 
 
We looked at this physician's review, the file, and Medicare rules. 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 acute inpatient psychiatric hospital care provided from May 5, 2023, through May 8, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
you would like a replacement chair to be approved because your original chair broke and is not repairable. The 
Plan denied your request. The Plan says that although there are three requested power options (tilt, recline and 
elevating leg rests), there is not a medical need to control these power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the complexity of your seating and positioning needs 
necessitates a more complex group 3 power wheelchair base. The expandable controller with harness and 
electronic connection are necessary to operate the group 3 power wheelchair base and the three power options 
via a joystick. Our reviewer also found that these components are required to operate 3 or more power options 
on a group 3 power wheelchair. 
 
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 electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
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 pre-approve an expandable controller (E2377), a harness for upgrade 
to expandable controller (E2313), electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), and hardware style (K0108).  

You asked the Plan to pre-approve an expandable controller, a harness, electronic connection, and hardware 
style. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity 
has not been established. Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an expandable controller, a harness, 
electronic connection, and hardware style. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found provided records do 
not document a need to control that the wheelchair's power functions through a joystick. Records indicate the 
enrollee has 4-/5 to 5/5 bilateral upper extremity strength and can perform his own self-care with modified 
independence, thus indicating he has adequate upper extremity strength and function to operate the wheelchair's 
power options with their own switches. Provided records in this case do not document a medical need for the 
K0108, Hardware option (a power mount). 
 
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 expandable controller, a harness, electronic connection, and hardware style 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller 
(E2377), a harness for upgrade to expandable controller (E2313), electronic connection between wheelchair 
controller and two or more power seating system motors (E2311), and hardware style (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 64721-AS-51-LT billed for date of service May 26, 
2023. 
 
You asked the Plan to pay for code 64721-AS-51-LT. You say that this claim was billed correctly, and you 
have provided medical records to support payment. The Plan denied your request. The Plan says assistant 
surgeons are not covered for the code in question. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 64721. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for code 
64721-AS-51-LT have not been met. Therefore, we decided that the Plan does not have to pay for code 64721-
AS-51-LT billed for date of service May 26, 2023.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the chiropractic services provided on January 3, 2023.

You asked the Plan to pre-approve the chiropractic services. You say that the service should be covered. The Plan denied your request. The Plan says that the provider has been excluded from coverage.

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. The appeal includes a letter showing the provider has been reinstated and the Plan has not submitted any evidence indicating otherwise. Therefore, we decided that the Plan has to pre-approve the chiropractic services provided on January 3, 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.