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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on May 5, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the item billed is missing required information. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket 
submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order 
number or details to corroborate the Delivery Ticket submitted. In addition, the Proof of Delivery is not 
itemized to indicate the specific supplies provided. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the lumbar-sacral orthosis provided on May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (01992) provided on July 20, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration because this 
claim was submitted with CPT codes that are billable and paid by Medicare. The Plan denied your request. The 
Plan says there are no records indicating why this member was given anesthesia for this procedure. 
 
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 pay for the anesthesia services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there was no indication for sedation administered by a separate provider. The 
member had no history of unstable medical conditions, morbid obesity or obstructive sleep apnea. 
 
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 anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for anesthesia services (01992) provided on July 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 25, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that your husband was treated in place by the 
medics. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 25, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the heart ultrasound provided on August 
13, 2020. 
 
You asked the Plan to waive the copayment for the heart ultrasound. You say that you were told the copayment 
should not be $160. You say you want the claim fixed and receive a revised bill. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
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 $160 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in an in-
network physician's office or at an in-network free-standing facility.  
 
You have been asked to pay a $160 copayment for the heart ultrasound. The heart ultrasound falls within the 
"Outpatient Diagnostic and Therapeutic Services and 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. Therefore, we decided that the Plan does not have 
to waive the copayment for the heart ultrasound provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services (97597) provided on July 23, 2020. 
 
You asked the Plan to pay for the wound care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were not pre-approved. There were network providers 
available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
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 wound care services (97597) provided on July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 9, 
2020. 
 
You asked the Plan to pay for the dental service. You say that your plan covers "2 routine periodic exams 
completed during check-up." You say that you have received 2 in the current year. You say that your plan also 
covers "1 limited exam to evaluate a problem." You also say that this is what was performed on this date of 
service. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The 
Plan says that the frequency limit has been exceeded. 
 
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, the frequency limit of 1 limited oral 
evaluation has been exceeded. The record shows that the Plan paid for the limited oral evaluation that you 
received on June 12, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on October 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance ride provided on August 6, 
2020. 
 
You asked the Plan to waive the copayment for the ambulance ride. You say that you were not informed about 
the $240 copayment. You say you only paid $50 copayment last year. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
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 $240 
copayment for each one-way Medicare-covered ground trip.  
 
You have been asked to pay a $240 copayment for the ambulance ride. The ambulance ride falls within the 
Ambulance 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 
ambulance ride provided on August 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99222) provided July 30, 2019. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician services was not filed until September 24, 2020. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for physician services (99222) provided July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the medical eye exam and the corneal 
pachymetry provided on September 22, 2020. 
 
You asked the Plan to waive the copayments for the medical eye exam and the corneal pachymetry. You say 
that you were told you would not have to pay for this and now you have to pay this bill. The Plan denied your 
request. The Plan says they made an error and you will only be responsible for the $5 copayment for the 
corneal pachymetry and you have been charged the correct cost sharing amount for the medical eye exam. 
 
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 Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes a $30 
copayment each basic imaging service (e.g., general x-rays or ultrasound).  
 
You have been asked to pay a $45 copayment for the medical eye exam and a $5 copayment, which is less than 
the standard copayment amount, for the corneal pachymetry. The medical eye exam falls within the Vision 
care benefit category. The corneal pachymetry falls within the Outpatient diagnostic tests and therapeutic 
services and 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. Therefore, we decided that 
the Plan does not have to waive the copayments for the medical eye exam and the corneal pachymetry provided 
on September 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial observation care (99219) provided on August 12, 
2020. 
 
You asked the Plan to pay for the initial observation care. You say that you would like reconsideration because 
the member received services from different providers. The Plan denied your request. The Plan says this 
service was billed on the same date as another evaluation and management service rendered by the same 
provider. 
 
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 99219 is not supported in the record. Specifically, the record indicates that another 
evaluation and management code for initial hospital care was billed and paid to the same provider for the same 
date of service. Per Medicare, only the initial hospital care will be paid in this instance. Based on this 
information, we decided that Medicare rules for coverage of the initial observation care have not been met. 
Therefore, we decided that the Plan does not have to pay for the initial observation care (99219) provided on 
August 12, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcatheter therapy (37211) provided on August 17, 
2020. 
 
You asked the Plan to pay for the transcatheter therapy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT Code 37211 exceeds the allowable 
units of service of 1 for the same date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 37211 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the transcatheter therapy have not been met. 
Therefore, we decided that the Plan does not have to pay for the transcatheter therapy (37211) provided on 
August 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on September 10, 2019. 
 
You asked the Plan to pay for the testing services. You say that the services may provide essential information 
for the enrollee's course of treatment. The Plan denied your request. The Plan says one HCPCS code must be 
submitted for the panel. 
 
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 the gene panel was not billed with one unit of service. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the lab testing provided on September 10, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on March 13, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim paid. The Plan denied your 
request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also 
out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 lab work provided on March 13, 2020 by an out of 
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction rendered on November 2, 2020. 
 
You asked the Plan to pay for these services. You say that you needed the refraction for upcoming cataract 
surgery. The Plan denied your request. The Plan says the services are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one routine eye exam per calendar year. 
 
We looked at the file and the Plan's rules. The file shows that you had an eye refraction prior to cataract 
surgery. These services are not covered by Medicare and are not covered by your supplemental benefit for a 
routine eye exam because they were performed for evaluation for cataract surgery. Therefore, we decided that 
the Plan does not have to pay for the eye refraction rendered on November 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services (G0299). 
 
You asked the Plan to pre-approve the home health services. You say that the home health services are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the home health services are not medically necessary. Our physician reviewer found the 
documentation doesnt support that the member requires skilled nursing services or skilled rehab services to 
provide treatment that is medically necessary. Furthermore, the documentation doesn't support that the enrollee 
is home bound. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services (G0299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says care can be provided in the current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The 
enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute 
care hospital. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee 
requires that are not available at the health care setting being offered by the health plan. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiological services provided on May 14, 2020. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says a modifier was not billed to represent the services as 
separate/distinct. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 73560 was not billed with a modifier to indicate the service was separately payable. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the radiological services provided on May 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral breast augmentation for male to female gender 
transition. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is a lack of psychological evaluation to determine whether this request is 
appropriate. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has declined female-related hormonal therapy, but would like the augmentation so 
as not to have to wear external prostheses. The examination does not does not adequately document the degree 
of any breast development present. Photographs were not provided for review. The enrollee has met with 
endocrinology, and is not interested in hormone therapy for transition from male to female.  The Plastic 
Surgery Office Clinic Note documents "she states she is not interested in a full transition, she mostly is 
interested in breast augmentation because she has dresses that he cannot wear external prosthetics with and she 
states she is tired of spending this much money on the external prosthetics because they do not last very long." 
The documentation does not support that the requested bilateral breast augmentation is medically reasonable 
and necessary for the enrollee in this case. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral breast augmentation for male to female gender transition.