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

 
We decided that the Plan does not have to waive the copayment for echocardiography provided on February 7, 
2020. 
 
You asked the Plan to waive the copayment for echocardiography. You say that you should not be responsible 
for the charges. 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 $50 
copayment for diagnostic procedures and tests.  
 
You have been asked to pay a $50 copayment for echocardiography. Echocardiography 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 copayment for echocardiography provided on February 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT, thorax; with contrast material(s) (CPT Code 
71260), CT, thorax; without contrast material, followed by contrast material(s) and further sections (71270) and 
CT, thorax; without contrast material (71250). 
 
You asked the Plan to pre-approve the CT scans. You say that this is precancerous testing and will save you 
money if you catch it before any symptoms arise. The Plan denied your request. The Plan says the services are 
not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scans. Our physician reviewer 
found based on current evidence based guidelines, for incidental nodules of less than 6mm in size, no routine 
follow-up is necessary especially in light of no change in the size of the nodules over time, as in the case of 
this. 
 
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 CT scans have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CT, thorax; with contrast material(s) (CPT Code 71260), CT, thorax; without contrast 
material, followed by contrast material(s) and further sections (71270) and CT, thorax; without contrast 
material (71250).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services provided from November 15, 2019, to December 6, 2019. 
 
You asked the Plan to pay for IRF care. You say that the enrollee would not have improved without these 
services. The Plan denied your request. The Plan says this was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 pay for 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 the complexity of the patient's nursing, medical and rehabilitation needs did not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for a stroke. Medical problems were stable and there were no medical problems requiring inpatient 
care. There were no complex nursing or rehabilitation needs. The patient did not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the record supports a need for physical and occupational therapy, there is no documented need 
for an intensive rehabilitation therapy program. 
 
 
 
 
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 pay for acute inpatient rehabilitation facility (IRF) admission and services provided from November 15, 
2019, to December 6, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on 
September 3, 2019. 
 
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 and the ordering 
physician also is not a Plan contract provider. 
 
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 ordering provider also was not in network. 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 out of network lab services provided to the enrollee on September 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear you received on July 27, 2020. 
 
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says the benefit limit has 
been paid. 
 
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 up to $300 every 12 months. 
 
We looked at the file and the Plan's rules. The records show that the Plan paid $300 toward the eyewear in 
question. Any amount over the $300 benefit limit is your responsibility. Based on this information, we decided 
that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does 
not have to pay for the eyewear you received on July 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fortelehealthservices provided to the enrollee on July 27, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the telehealth criteria in place at the time of service were not met.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. At the time of service, the enrollee did not meet the required telehealth coverage criteria. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay fortelehealth services provided to the enrollee on July 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for2 lines of 2 units each (4 units total) of needle electromyography (95870) provided on January 14, 2020.You asked the Plan to pay for4 units of needle electromyography. You say that this is documented in the records.The Plan denied your request. The Plan says this number of units is notsupported.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 4 units of needle electromyography Our reviewer says that the units billed are not supported in the medical records. Our physician reviewer found the reporting of 2 lines of 2 units each, totaling 4 units, of CPT code 95870 is not supported by the medical records submitted. The documentation is insufficient to verify services reported.We looked at this physician's review, the file, and Medicare rules. Based on this information,we decided that Medicare rules for coverage of 4 units of needle electromyography have not been met.Therefore, we decided that the Plan does not have to pay for2 lines of 2 units each (4 units total) of needle electromyography (95870) provided on January 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a 
participating provider on June 22, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you do not know why 
you are being charged this much. 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 $270 
copayment for outpatient surgery.  
 
You have been asked to pay $158.22 which is less than your copayment amount of $270 copayment for 
outpatient hospital services. When services are provided at an outpatient hospital associated facility an 
outpatient hospital facility copayment can be applied; therefore, the correct copayment has been applied. 
Outpatient hospital services fall within the outpatient surgery 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 outpatient hospital services provided by a participating provider on June 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
You asked the Plan to pre-approve 12 additional physical therapy visits. You say that the enrollee returns to 
baseline over several months of not receiving services. You say that she would benefit from skilled therapy 
services. The Plan denied your request. The Plan says additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 12 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer says that the unique skills of a professional 
therapist are not required to safely and effectively provide ongoing treatment. 
 
 
  
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 12 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 8, 2019 to December 9, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says the services were not emergent, and did not meet the inpatient level of care 
criteria. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee did well, tolerated oral intake, and was discharged home the following 
day. Care provided to the enrollee was observation level. There were no advance interventions or complex 
medical conditions. Inpatient are services were not supported by the documentation. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee from December 8, 2019 to 
December 9, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a 
participating provider. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you were told that you 
would only owe about $100. 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 $275 
copayment for outpatient surgery/in-network/ambulatory surgical center.  
 
You have been asked to pay a $275 copayment for a diagnostic colonoscopy. When a colonoscopy is provided 
due to a complaint, the colonoscopy becomes diagnostic; therefore, the correct copayment has been applied to 
the diagnostic colonoscopy that was provided. A diagnostic colonoscopy falls within the outpatient surgery/in-
network/ambulatory surgical 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 a 
diagnostic colonoscopy provided by a participating provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on September 20, 2019. 
 
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 25660 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 25660 is closed treatment of radiocarpal or intercarpal 
dislocation, 1 or more bones, with manipulation. 
 
We find that CPT code 25660 is not supported in the medical record. Specifically, there is no documentation of 
closed treatment of radiocarpal or intercarpal dislocation of one or more bones with manipulation was 
performed. 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 surgical services rendered on 
September 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
July 14, 2020 to July 18, 2020. 
 
You asked the Plan to waive the copayment for the inpatient services. You say that you are on social security 
disability and barely make enough money to get by . The Plan denied your request. The Plan says the claim 
processed with the correct copayment applied per the plan's 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 $300 
copay per day for days 1-5 on Medicare covered inpatient hospital stay.  
 
You have been asked to pay $900 for the inpatient services. The inpatient services fall 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 the inpatient hospital 
services provided July 14, 2020 to July 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased out of network on February 26, 2020.  
 
You asked the Plan to pay for out of network hearing aids. You say that the provider told you they had prior 
authorization. The Plan denied your request. The Plan says the provider did not have prior authorization for 
hearing aids and therefore you did not have prior authorization for out of network hearing aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan only pays 
for hearing aids from specific providers. The provider used is not in network and did not have prior 
authorization. Therefore, we decided that the Plan does not have to pay for hearing aids purchased out of 
network on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional 60 minutes of critical care services (99292x2) 
provided on July 21, 2019. 
 
You asked the Plan to pay for the additional critical care services. You say that you would like reconsideration 
because the services rendered were medically necessary. The Plan denied your request. The Plan says the 
documentation does not support that an additional 60 minutes of critical care services were rendered in addition 
to the initial 30-74 minutes. 
 
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 99292x2 is critical care, evaluation and management of 
the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
We find that CPT code 99292x2 is not supported in the record. Specifically, the records indicate that a total of 
50 minutes was spent rendering critical care services. This does not support that 60 additional minutes of 
critical care services were rendered in addition to the initial 30-74 minutes. Based on this information, we 
decided that Medicare rules for coverage of the additional critical care services have not been met. Therefore, 
we decided that the Plan does not have to pay for an additional 60 minutes of critical care services (99292x2) 
provided on July 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extra heavy duty wheelchair (K0007) provided April 19, 
2020 
 
You asked the Plan to pay for the extra heavy duty wheelchair. You say that the item was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the item billed. 
 
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. 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 an extra heavy duty wheelchair (K0007) provided April 19, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210), the bone replacement graft 
for ridge preservation (D7953), and the guided tissue regeneration (D4266) provided on March 10, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are having an implant done. You say that 
the services you received so far have all denied. You say that your Evidence of Coverage does not state that 
any of the services you received are not covered. You say that it states clearly that extractions, oral surgery and 
implants are covered. The Plan denied your request. The Plan says there is a 50% coinsurance of the covered 
plan allowance after the $100 annual deductible is met. The Plan says bone replacement graft for ridge 
preservation is not listed as a covered service. The Plan also says that guided tissue regeneration is not listed as 
a covered service. 
 
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 and surgical extractions are listed as a 
covered service, there is a $100 deductible that you must pay before the Plan will pay their share of the cost for 
 
 
your covered dental services. Additionally, the bone replacement graft and guided tissue regeneration are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
surgical extraction (D7210), the bone replacement graft for ridge preservation (D7953), and the guided tissue 
regeneration (D4266) provided on March 10, 2020.