Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Ophthalmological services; medical 
examination and evaluation with initiation or continuation of diagnostic and treatment program (92014) 
provided on July 10, 2020. 
 
You asked the Plan to waive the copayment for diagnostic eye exam. You say that the copayment should be 
waived. The Plan denied your request. The Plan says the copayment was applied 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 $35 
copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes for vision 
care.  
 
You have been asked to pay a $35 copayment for diagnostic eye exam. This service falls within the vision 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. 
Therefore, we decided that the Plan does not have to waive the copayment for Ophthalmological services; 
medical examination and evaluation with initiation or continuation of diagnostic and treatment program 
(92014) provided on July 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urethrectomy, total, including cystostomy (53210) and total 
abdominal hysterectomy (corpus and cervix) with or without removal of tube(s), with or without removal of 
ovary (58150) provided on August 5, 2019. 
 
 
 
You asked the Plan to pay for the surgical procedure. You say that your coding unit indicated on the attached 
operative report where procedure code 58150 was documented and you request the denial be reviewed and 
payment for this code be made. The Plan denied your request. The Plan says the records do not support the 
billed service. 
 
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 the 
surgical procedure 53210 has a bundled relationship with code 51595 and cannot be paid as billed. This code 
cannot be paid as a separate line item. We also find that CPT code 58150 is not supported in the medical 
record. Specifically, the submitted documentation does not support removal of the cervix was performed. There 
is a different code that represents the procedure performed. The correct code for 58150 would be 58180 
(supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), without or 
without removal of ovary(s). Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for urethrectomy, total, including cystostomy (53210) 
and total abdominal hysterectomy (corpus and cervix) with or without removal of tube(s), with or without 
removal of ovary (58150) provided on August 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for replacement headset/headpiece for use with cochlear implant 
device (L8615) replacement microphone for use with cochlear implant device (L8616) and replacement 
cochlear implant, external speech processor and controller, integrated system (L8619) 
 
You asked the Plan to pay for the cochlear implant and supplies. You say that you were told to attach the proof 
of delivery and LMN so they can process again for payment. Please reconsider the claims for payment. The 
Plan denied your request. The Plan says the billed service cannot be verified. 
 
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 physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The documentation submitted did not include a 
valid physician order for the billed date of service. Documentation submitted included an order, but the 
physician signature was dated after the billed date of service. Of note, the signature date is considered the date 
of the order when no other date is specified. 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 
replacement headset/headpiece for use with cochlear implant device (L8615) replacement microphone for use 
 
 
with cochlear implant device (L8616) and replacement cochlear implant, external speech processor and 
controller, integrated system (L8619)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided by an out 
of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that it is the nursing facility's responsibility to 
obtain prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 skilled nursing services provided by an out 
of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic treatment provided. 
 
You asked the Plan to pay for the chiropractic treatment. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or the 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
chiropractic treatment. 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 chiropractic treatment provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for testing services provided to the enrollee on June 22, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 in this case is not a network provider with the Plan. 
The Plan has network providers available who can provide 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 testing services provided to 
the enrollee on June 22, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home sleep study (95806). 
 
You asked the Plan to pre-approve the home sleep study. You say that you are unable to sleep at night. You 
have lung problems and cannot breathe and Melatonin does not help. The Plan denied your request. The Plan 
says Medicare guidelines says you must not have other lung diseases. The records show the enrollee has 
chronic lung conditions. Therefore, the enrollee does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home sleep study have not been met. Therefore, we decided that the Plan does not have to pre-
approve the home sleep study (95806).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 8, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee 
does not have out-of-network benefits. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician?s services. 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 physician's services provided on July 8, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that all charges, except for therapies, telehealth 
originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance 
services are combined and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient).  
 
We looked at the file and Medicare rules. The IHS hospital must bill all outpatient services under revenue code 
0510. This was not done in this case. 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 the services 
provided on March 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 15, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
the Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on June 15, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee is at baseline with no skilled needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-contracted tertiary level provider. 
 
You asked the Plan to pre-approve the services. You say that you need to see this specialist in order to have 
your surgery and you claim that if you does not get the surgery you can die. The Plan denied your request. The 
Plan says your treatment can be safely rendered in-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 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 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 
non-contracted tertiary level provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergent transportation trips. 
 
You asked the Plan to pre-approve the additional trips . You say that this is medically necessary. The Plan 
denied your request. The Plan says benefits have been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergent transportation trips.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the group psychotherapy services provided on January 15, 
2020 billed with code 90853 with modifier -59. 
 
You asked the Plan to pay for the group psychotherapy services as billed. You say that it is felt that this was 
billed correctly and that at least one unit should be paid. The Plan denied your request. The Plan says it was 
decided to approve payment for 90853, but there is no evidence that payment is due to 90853-59. 
 
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 90853-59 is Group psychotherapy (other than of a 
multiple-family group) with the modifier meaning that it is a distinct procedural service. 
 
We find that CPT code 90853-59 is not supported in the medical record. Specifically, there is nothing in the 
note submitted which would verify that additional services that were distinct and separate were provided 
beyond those reimbursed via code 90853 without the modifier. Based on this information, we decided that 
Medicare rules for coverage of the group psychotherapy services as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the group psychotherapy services provided on January 15, 2020 
billed with code 90853 with modifier -59.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by an out-of-
network provider on May 1, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that no one could control whether 
or not the ambulance was in-network. The Plan denied your request. The Plan says the correct copayments 
have been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $225 copayment for each one-way trip for ambulance services/out-of-network.  
 
The enrollee has been asked to pay a $225 copayment for each one-way trip for an ambulance trip. The total 
amount that is being asked to pay is $450 ($225 x 2 trips = $450). The same copayment would be applied to an 
in-network provider as well. An ambulance trip falls within the ambulance services/out-of-network benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an ambulance trip provided by 
an out-of-network provider on May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 24, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the office visit. You say that the visit should be covered under a visitor and 
domestic travel plan. The Plan denied your request. The Plan says they do not offer a visitor and domestic 
travel plan option and the office visit was non-emergent. 
 
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 in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide 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 the medical services provided on June 24, 2020 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultraviolet light system purchased on February 5, 2020. 
 
You asked the Plan to pay for out of network durable medical equipment. You say that this equipment was 
medically necessary. The Plan denied your request. The Plan says you did not have prior authorization to 
purchase durable medical equipment 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 Plan contract states that durable medical equipment requires 
prior authorization.   
 
The provider was not in network and you did not have prior authorization for this equipment. Therefore, we 
decided that the Plan does not have to pay for an ultraviolet light system purchased on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on March 3, 2020. 
 
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says the 
services are not authorized to be rendered by a provider other than one participating in the Plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
chiropractic services. 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 chiropractic services provided on March 3, 2020.
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 LTACHs do not provide a clinical advantage over a non-LTACH acute care 
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. In this case, ongoing care needs include oxygen supplementation, intermittent BiPAP, nebulizer 
treatments, steroids, surveillance laboratory studies, and therapy services. The documentation does not support 
that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital 
where he is currently receiving care. There are no required medical services identified that are available at the 
LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, 
the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee at this time. 
 
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.