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

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on April 7, 2023. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you should not be responsible to pay a 
copayment for a screening test ordered by your physician. 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 up to a 
$300 copayment for diagnostic radiology services.   
 
  You have been asked to pay $52.97, which is less than the standard copayment for a CT scan. This item/service 
falls within the outpatient diagnostic tests 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 CT scan provided on April 7, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 36620 and 93312 billed for date of service September 
9, 2022. 
 
You asked the Plan to pay for procedure codes 36620 and 93312. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says that the provided records do not support procedure 
code 36620. Payment for code 93312 is bundled into payment for code 00560. 
 
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, the Plan has not forwarded medical documentation to support its 
denial rationales. It is the Plan's responsibility to support its denial with evidence. In this case, the Plan's denial 
rationales are not supported, so we must find in your favor. Therefore, we decided that the Plan has to pay for 
procedure codes 36620 and 93312 billed for date of service September 9, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the manual swingaway (E1028) and Elite Headrest 
Adapter (K0108). 
 
You asked the Plan to pre-approve the manual swingaway and Elite Headrest Adapter. You say that the items 
are medically necessary. The Plan denied your request. The Plan says the elite headrest adapter in considered 
unbundling and not covered. The enrollee does not need a manual swingaway as they cannot perform a slide 
transfer. 
 
The Plan follows Medicare rules. Medicare rules say that items 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 manual swingaway and Elite 
Headrest Adapter. Our reviewer says that the items are not medically necessary. Our physician reviewer found 
the documentation doesnt support that the member is able to perform a slide transfer into a bed or chair. 
 
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 manual swingaway and Elite Headrest Adapter have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the manual swingaway (E1028) and Elite 
Headrest Adapter (K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria guidelines. 
You would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
admission to an IRF is not medically necessary.  
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a myocardial perfusion imaging provided on 
February 14, 2023. 
 
You asked the Plan to waive the cost share for a myocardial perfusion imaging. You say that you were not 
informed of the cost share prior to the procedure. 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 $750 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. Your contract with the Plan also clearly says that you must pay a $295 
copayment for in-network nuclear medicine services. 
 
 You have been asked to pay $750, which satisfies the deductible for the myocardial perfusion imaging. The 
item or service you asked the Plan to waive the cost share for falls within the outpatient diagnostic tests and 
therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is a $750 deductible which applies to outpatient diagnostic tests and therapeutic 
services and supplies. This cost sharing is a contractual obligation that had not been met at the time a 
myocardial perfusion imaging was received on February 14, 2023.  
 
You have also been asked to pay a $295 copayment for the myocardial perfusion imaging. This item/service 
falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. You have 
been asked to pay a total of $1,045 ($750 deductible + $295 copayment = $1,045). 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 cost share for a myocardial perfusion imaging provided on February 14, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for  procedure code 81455 billed for date of service July 13, 2022. 
 
You asked the Plan to pay for  the billed services. You say that the medically necessary criteria were met. The 
Plan denied your request. The Plan says that the billed date of service is incorrect. 
 
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. 
 
We looked at the file and the rules. The Plan has not proven that the date of service is incorrect. The Plan has 
not shown that the lab tests does not meet one of the exceptions for the date of service. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request. Therefore, we decided that the Plan has to pay for  procedure code 81455 billed for date of service July 
13, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services with physician 
oversight of therapy, monitoring of medical conditions and all other medical needs. The Plan denied your 
request. The Plan says admission to an IRF is not reasonable and necessary.  
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on September 1, 2022, to 
September 27, 2022. 
 You asked the Plan to pay for home health services. You say that you are requesting reconsideration and have 
submitted medical records for review. The Plan denied your request. The Plan says the NOA was not received 
timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 1, 2022. The NOA was not received by the Plan until November 
3, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on September 1, 2022, to September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation - problem focused (D0140) 
provided on October 12, 2022. 
 
You asked the Plan to pay more for the limited oral evaluation - problem focused. You say that you were 
quoted by the provider before the service was rendered, the pre-determination estimate was $0 and the 
insurance estimate was $143. You also say that you disagree with the claim processing. 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 limited oral evaluation - problem focused 
(D0140) provided on October 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 heavy duty power wheelchair (PWC) with a 
patient weight capacity 301 to 450 pounds (K0824) and additional items and accessories (codes E2361 x2, 
E1028, K0108, E0973 x2, and E2603). 
 
You asked the Plan to pre-approve a Group 2 heavy duty PWC and additional items and accessories. You say 
that the denial letter states you must weigh between 285 and 450 pounds, and you are weighing 285 pounds. 
You also say that at this time, you are using you walker, but can tell your legs are getting weaker and weaker, 
and you need the wheelchair to get around. The Plan denied your request. The Plan says the criteria for a 
heavy-duty power wheelchair have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 2 PWC (such as code K0824) is covered 
if the wheelchair is appropriate for the beneficiarys weight. Medicare rules also say that if the PWC base is not 
covered, then related accessories will be denied. 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Group 2 heavy duty PWC have not been met. Specifically, the provided records show that your 
most recent documented weight is below the required weight limit of 301 to 450 pounds for a Group 2 heavy 
duty PWC (K0824). Therefore, we decided that the Plan does not have to pre-approve a Group 2 heavy duty 
power wheelchair (PWC) with a patient weight capacity 301 to 450 pounds (K0824) and additional items and 
accessories (codes E2361 x2, E1028, K0108, E0973 x2, and E2603).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services, a computed tomography 
(CT) scan and an office visit provided on February 2, 2023, to February 13, 2023. 
 
You asked the Plan to waive the copayment for x-ray services, a CT scan and an office visit. You say that you 
disagree with the copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for outpatient diagnostic tests/Medicare-covered x-ray, a $295 copayment for outpatient diagnostic 
tests/Medicare-covered CT scan and a $5 copayment for and physician/practitioner services/Medicare-covered 
primary care physician.  
 
You have been asked to pay a $30 copayment for x-ray services, a $295 copayment for a CT scan and a $5 
copayment for an office visit. The total amount you are being asked to pay is $330 ($30 + $295 + $5 = $330). 
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 x-ray services, a computed tomography (CT) scan and an 
office visit provided on February 2, 2023, to February 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that in consideration of the enrollee's prior medical 
history, active comorbidities and risk for medical instability while increasing activity, the IRF setting is the 
most appropriate to reach the desired outcomes. The Plan denied your request. The Plan says admission to an 
IRF is not medically necessary.  
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64646 and J0585 billed for date of service 
November 14, 2022. 
 
You asked the Plan to pay for the billed services. You say that the codes were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the 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. We find that CPT codes 64646 and J0585 are not supported in the medical record. Specifically, the records do 
not include documentation of failed conservative treatments such as medication, physical therapy, or other 
conventional methods. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
64646 and J0585 billed for date of service November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation - problem focused (D0140) 
provided on April 19, 2023. We also decided that the Plan does not have to pay for the resin-based composite - 
four or more surfaces or involving incisal angle (anterior) tooth #8 (D2335) provided on May 2, 2023. 
 
You asked the Plan to pay more for the limited oral evaluation. You also asked the Plan to pay for the resin-
based composite  four or more surfaces. You say that it is your opinion that the payments for this injury 
should fall under the general medical coverage category rather than being covered under the dental part of your 
policy. You also say that this is not general dental work but rather medical treatment resulting from an injury 
by falling. 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. The Plan also 
says your benefit for the resin-based composite 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 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 limited oral evaluation - problem focused 
(D0140) provided on April 19, 2023. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the resin-based composite was exhausted on date of service April 21, 2023. Therefore, 
we decided that the Plan does not have to pay for resin-based composite - four or more surfaces or involving 
incisal angle (anterior) tooth #8 (D2335) provided on May 2, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the walker (E0143) provided on March 13, 2023. 
 
You asked the Plan to pay for the walker (E0143). You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for the walker (E0143) based on Medicare criteria. The Local Coverage Determination and Article the 
Plan bases their denial on does not specifically state that the KX modifier must be billed with code E0143. 
Therefore, we decided that the Plan has to pay for the walker (E0143) provided on March 13, 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.