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

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 23, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Medicare denies coverage for all cardiovascular risk assessment testing /panels.

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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid
panel, for symptomatic patients for suspected or documented cardiovascular-respiratory disease. The laboratory
services provided to the enrollee on July 23, 2020 were not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for laboratory services provided to the enrollee on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hearing exam provided by a participating
provider on March 23, 2021.
You asked the Plan to waive the copayment for a hearing exam. You say that you were never told that you
would have a copayment for this. You say that you already had a hearing exam done. 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 $30
copayment for routine hearing services/in-network.
You have been asked to pay a $30 copayment for a hearing exam. The correct copayment has been applied to
the services that were provided. A hearing exam falls within the routine hearing services/in-network 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 hearing exam provided by a participating
provider on March 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the remote interrogation device evaluation,
up to 90 days (93294, 93296) provided February 25, 2021.

You asked the Plan to waive the copayment for the diagnostic services. You say that you have received 2 bills
for this and would like to appeal the copay. The Plan denied your request. The Plan says the claim was
processed with the correct copayment applied per the Evidence of Coverage

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 $30
copayment for Medicare covered non-radiological diagnostic services.

You have been asked to pay $30 copayment for the diagnostic services. The diagnostic services fall 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 copayment for the remote interrogation device evaluation, up to 90 days (93294, 93296) provided
February 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for immunohistochemistry testing (88342-59, 88341-59)
provided on April 1, 2021.
You asked the Plan to pay for immunohistochemistry testing. You say that these codes are documented and
payable. The Plan denied your request. The Plan says this use of modifier -59 is not appropriate.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the
service billed with the modifier indicates a distinct procedural service.
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural
service. Specifically, the documentation does not support that the testing at issue was performed on a different
session or patient encounter, different procedure or surgery, different site, or organ system, separate
incision/excision, or separate injury from the other services billed on this claim. Based on this information, we
decided that Medicare rules for coverage of services billed with a -59 modifier have not been met.
Therefore, we decided that the Plan does not have to pay for immunohistochemistry testing (88342-59, 88341-
59) provided on April 1, 2021.
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 enrollee needs IRF care. The Plan denied your
request. The Plan says the enrollee can safely receive services needed in other settings.

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 there are no complex nursing or rehabilitation needs. The patient does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the documentation does support a need for physical and/or 
occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 
There is not a reasonable expectation that this patient 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (upper GI endoscopy) you had on March 23, 2021, at an ambulatory surgery center.

You asked the Plan to waive the copayment for the upper GI endoscopy. You say that you are on a limited income and cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $175 copayment for visits to an ambulatory surgery center. 

You have been asked to pay a $175 copayment for the upper GI endoscopy. The upper GI endoscopy falls within the visits to an ambulatory surgery center 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 esophagogastroduodenoscopy (upper GI endoscopy) you had on March 23, 2021, at an ambulatory surgery center.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 29, 2021 by an outof-
network (OON) provider.

You asked the Plan to pay for the medical services. You say that these services were medically necessary. The
Plan denied your request. The Plan says unauthorized, non-plan care is not covered.

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.

Your organization 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 services 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 the medical services provided on March 29, 2021 by an OON
provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray of the chest (71045) provided to the enrollee on March
25, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the claim denied as duplicate in error.

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 71045
has a bundled relationship with code 74022 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for x-ray of the chest (71045) provided to the enrollee on March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 28, 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 the testing is not covered.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a removal of biliary drainage catheter (47537) provided on
February 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an outpatient procedure. You say that you called the Plan for authorization on a
different procedure. You also say you did the above procedure instead and is requesting a retro authorization
for the corrected procedure. The Plan denied your request. The Plan says services were provided by an out-ofnetwork
provider without prior authorization.
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 a removal of biliary drainage catheter (47537)
provided on February 23, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99212) provided April 1, 2021.
You asked the Plan to pay for the chiropractic services. You say that you called prior to seeing the chiropractor
and was told that this was a required service prior to getting approval for further chiropractic care. The Plan
denied your request. The Plan says this service is not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the outpatient office visit (99212) provided April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 8, 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 the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the diabetic shoe inserts and fitting that you received on March 4, 2021.

You asked the Plan to waive the coinsurance for the diabetic shoe inserts and fitting. You say that you have never had to pay for these inserts in the past. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that you had a different insurer in previous years, so they may have had a different cost sharing structure.

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 20% coinsurance for therapeutic shoes and inserts for persons with diabetes. 

You have been asked to pay 20% coinsurance for the diabetic shoe inserts and fitting. The diabetic shoe inserts and fitting fall within the therapeutic shoes and inserts for persons with diabetes 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 coinsurance for the diabetic shoe inserts and fitting that you received on March 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient mental health stay provided by
a participating provider on February 17, 2021, to February 20, 2021.

You asked the Plan to waive the copayment for an inpatient mental health stay. You say that you do not agree
with this copayment. 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 per day for days 1-7. There is a $0 copayment for additional days for inpatient mental health care.

You have been asked to pay a $100 copayment per day for days 1-3 for an inpatient mental health stay. The
total amount you are being asked to pay is $300 ($100 x 3 days = $300). An inpatient mental health stay falls
within the inpatient mental health 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
an inpatient mental health stay provided by a participating provider on February 17, 2021, to February 20,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic shoes provided on February 27, 2021 by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for diabetic shoes. You say that you were told you could go out-of-network due to
the pandemic. You say that you need this specific type of shoe. The Plan denied your request. The Plan says
prior authorization was not obtained for this durable medical equipment.
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 diabetic shoes provided on February 27, 2021 by
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction provided on April 8, 2021.

You asked the Plan to pay for determination of refractive state (92015). You say that this service should be covered by the Plan. The Plan denied your request. The Plan says this service is not covered by the Plan or by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. 

The services you asked the Plan to pay for are considered routine vision services. Therefore, we decided that the Plan does not have to pay for eye refraction provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on February 25, 2020.
You asked the Plan to pay for the office visit, electric stimulation therapy and x-rays. You say that you are on a
fixed income and don't understand the non-covered charges. The Plan denied your request. The Plan says office
visits, electric stimulation therapy and x-rays are never covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for the chiropractic services provided on February 25, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on May 6, 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 97110 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 97110 is therapeutic procedure, 1 or more areas, each 15
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows
that the services were performed in the home setting and there is a more appropriate code for these services.
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 physical therapy services rendered on May 6,
2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided April 3,
2021.
You asked the Plan to pay for the CT scan. You say that the services were medically necessary. The Plan
denied your request. The Plan says payment for this code is bundled with payment for another 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 70450
has a column I / column II relationship with code 70496 and cannot be paid as billed. This code cannot be paid
as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore,
we decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided April 3,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that
were issued on April 26, 2021.

You asked the Plan to pay for the compression stockings. You say that you know you can only get four pair in
one year, but you were unaware that you have to wait 6 months to get new pairs. The Plan denied your request.
The Plan says this service exceeds the maximum benefit limitation.

The Plan must follow Medicare rules. The health plan has a benefit that exceeds Medicare coverage. For that
reason, the Plan's coverage rules apply in this case. The health plan contract says that the plan covers 2 pairs of
gradient compression stockings every 6 months or up to 2 pairs of surgical stockings every 6 months. The
records show that the last pair of compression stockings was provided to the enrollee on December 22, 2020.
This is within the 6-month time limit and exceeds the Plan's benefit.

Although this item may be appropriate, the benefit has been exhausted and cannot be paid for by Medicare or
the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified
with code A6530 that were issued on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral to an oncologist.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is no gap issue, and there are in-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 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 an out-of-network referral to an oncologist.