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

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided July 29, 
2020 to August 1, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not feel that 
you should be charged 3 days of inpatient copay. You were in the ED hallway for approximately 14 hours 
receiving blood transfusions before getting a room at 3 am. The Plan denied your request. The Plan says the 
claim processed and the correct copayment applied per the plan benefits. 
 
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 $380 
copayment per day for days 1-5 for covered hospital care. for inpatient hospital care.  
 
You have been asked to pay $1,140.00 ($380 x 3 days = $1,140.00) for the inpatient hospital stay. The 
inpatient hospital stay falls within the inpatient hospital 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 inpatient hospital care provided July 29, 2020 to August 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the determination of refractive state 
(92015) and medical eye exam (92004) 
 
You asked the Plan to waive the copayment for the determination of refractive state and medical eye exam. 
You say that you disagree with the bill as charged. The Plan denied your request. The Plan says the copayment 
processed correctly. 
 
 
You have been asked to pay $25 for the medical eye exam. This service falls within the Medicare-covered eye 
exam 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 medical eye exam. 
 
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 these services when they are provided by the Plan's routine eye service vendor. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the determination of refractive state have not been met. You need to reach out to the Plan's routine 
eye service vendor for coverage. Therefore, we decided that the Plan does not have to waive the copayment for 
the determination of refractive state.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on February 17, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were told that your copayment 
would be $40. The Plan denied your request. The Plan says the correct copayment has 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). Your contract with the Plan clearly says that you must pay a $100 
copayment for outpatient diagnostic tests/diagnostic test/outpatient hospital.  
 
You have been asked to pay a $100 copayment for an ultrasound. An ultrasound falls within the outpatient 
diagnostic tests/diagnostic test/outpatient hospital benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an ultrasound provided by a participating provider on February 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve One Care Connect for the Freestyle lite test strip. 
 
You asked the Plan to pre-approve the supplies. You say that you currently have a meter and tests strips but 
they are not working for you because the machine is too complicated and cheap. The Plan denied your request. 
The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the supplies have not been met. Your doctor stated that you do not 
have a current diagnosis of diabetes, you are not currently taking diabetes medicines, and that diabetes testing 
is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve One Care Connect 
for the Freestyle lite test strip.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 15, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges 
because this was a post-operative visit. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct 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 $35 
copayment for each visit to a specialist. 
 
You had a specialist visit on June 15, 2020. Post-operative visits are subject to cost-sharing charges. Therefore, 
you are responsible to pay the $35 copayment.   
 
You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor?s office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist visit provided on June 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found 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 was admitted for gangrenous lesion of left lower 
extremity and had a left above the knee amputation. Medical problems are stable. There are no identified 
problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. 
  
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not 
a reasonable expectation that this 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services rendered on March 25, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes J1580 and 96372 are not supported. 
 
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 J1580 is injection, garamycin, gentamicin, up to 80 mg. 
The definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); 
subcutaneous or intramuscular. 
 
We find that CPT codes J1580 and 96372 are not supported in the medical record. Specifically, there is no 
documentation of an injection of garamycin/gentmicin of up to 80 mg was administered to support code J1580. 
There is no documentation of a therapeutic, prophylactic, or diagnostic injection to support code 96372. 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 injection services rendered on March 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace (L0650) provided on February 27, 2020. 
 
You asked the Plan to pay for the back brace. You say that you would like reconsideration because the Plan's 
denial is negligent. The Plan denied your request. The Plan says the member has denied receiving a back brace 
or ever speaking to the ordering physician. 
 
 
 
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 back brace. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found an appropriate history and a physical examination of the back would reasonably be required to 
adequately assess whether the coverage criteria for lumbar-sacral orthosis have been met. The documentation 
does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in 
this case, as there is insufficient documentation of a credible physical examination of the back. 
 
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 back brace have not been met. Therefore, we decided that the Plan does not 
have to pay for the back brace (L0650) provided on February 27, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that the requested Gelsyn-3 is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Monovisc first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gelsyn-3. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with bilateral knee 
osteoarthritis. Gelsyn-3 was requested. The provided documentation states that the enrollee has not yet tried 
and failed Monovisc or Orthovisc for the knee arthritis. Nor was there documentation stating any 
contraindication or other cause for using Gelsyn-3 over these preferred agents. Current evidence shows similar 
efficacy and side effects with all available hyaluronic acid injectables such as these, suggesting no increase in 
 
 
risk or decrease in efficacy if the enrollee tried one of the preferred agents. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided. 
 
You asked the Plan to pay for the assistant services. You say that the surgical assistant was chosen by the 
operating surgeon. The Plan denied your request. The Plan says services of an assistant surgeon are not covered 
for this procedure. 
 
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 CPT code 23075. 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 the assistant services have not been met. Therefore, we decided that the Plan does not have 
to pay for the assistant surgeon services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG) continuous recording, with 
video when performed, setup, patient education, and takedown when performed, administered in person by 
EEG technologist, minimum of 8 channels (CPT Code 95700) and electroencephalogram with video (VEEG), 
review of data, technical description by EEG technologist, each increment of 12-26 hours; with intermittent 
monitoring and maintenance (95715 x4) provided from May 14, 2020, through May 17, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 services. Our physician reviewer found 
the documentation submitted was reviewed, and does not meet criteria. The documentation did not include 
video to confirm service was performed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for electroencephalogram (EEG) continuous recording, with video when performed, setup, patient 
education, and takedown when performed, administered in person by EEG technologist, minimum of 8 
channels (CPT Code 95700) and electroencephalogram with video (VEEG), review of data, technical 
 
 
description by EEG technologist, each increment of 12-26 hours; with intermittent monitoring and maintenance 
(95715 x4) provided from May 14, 2020, through May 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A9270. 
 
You asked the Plan to pre-approve the compression stockings. You say that this is needed to avoid further trips 
to the hospital. The Plan denied your request. The Plan says the requested supplies are statutorily not covered 
by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A9270 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A9270.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood bank physician services (86078) provided January 14, 
2020. 
 
You asked the Plan to pay for blood bank physician services. You say that this was medically necessary. The 
Plan denied your request. The Plan says an additional unit is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 blood bank physician services Our reviewer 
says that an additional unit of 86078 is not supported. Our physician reviewer found one unit of CPT code 
86078 was previously. The medical record does not include documentation of additional services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of blood bank physician services have not been met. Therefore, we decided that 
the Plan does not have to pay for blood bank physician services (86078) provided January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Ultra Blue test strips. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says OneTouch is not the preferred brand. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans can limit enrollees to preferred brands of 
durable medical equipment and supplies. 
 
We looked at the file and Medicare rules. The services at issue are OneTouch test strips. OneTouch is not the 
preferred brand for diabetic testing strips. The Plan provides diabetic testing supplies from FreeStyle and 
Precision Xtra. Therefore, we decided that the Plan does not have to pre-approve OneTouch Ultra Blue test 
strips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the outpatient surgical services and 
imaging services rendered from July 20, 2020 to July 21, 2020. 
 
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the cost sharing was applied 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 $500 yearly deductible for your covered medical services and a $325 
copayment for Medicare-covered surgery or other services provided to you at hospital outpatient facilities. 
 
Review of the file should that you received an ultrasound on July 20, 2020. These services fall within the 
Medicare-covered radiological diagnostic service, not including x-rays, benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is $500 yearly deductible for your covered 
medical services. This cost sharing is a contractual obligation that had not been met at the time these services 
were received on July 20, 2020. The Plan applied $135.78 to your deductible for these services. 
 
The file shows that you received outpatient surgical services to your bladder on July 21, 2020. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is $500 yearly deductible for your 
covered medical services. This cost sharing is a contractual obligation that had not been met at the time these 
services were received on July 21, 2020. The Plan applied $228.87 to your deductible for these services. At this 
time, your yearly deductible had been met. 
 
Given that the $228.87 deductible did not cover the entire cost of these services, you have also been asked to 
pay a copayment for these services. The contract with the Plan states that there is a $325 copayment for 
Medicare-covered surgery or other services provided to you at hospital outpatient facilities. However, the 
remaining Medicare allowed amount for these services after the deductible charge was $60.71. Given that the 
allowed amount was less than the $325 copayment, you have been asked to pay $60.71 for these services.  
 
The total amount you have been asked to pay for these services is $420.36. This cost sharing is a contractual 
obligation that you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not 
have to waive the cost sharing for the outpatient surgical services and imaging services rendered from July 20, 
2020 to July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on March 11, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 01214 is not supported. 
 
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 01214 is anesthesia for open procedures involving hip 
joint; total hip arthroplasty. 
 
We find that CPT code 01214 is not supported in the medical record. Specifically, there is no documentation of 
anesthesia for an open procedure involving the hip joint. 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 anesthesia services rendered on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
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 
a referral to an out-of-network provider.