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

 
We decided that the Plan does not have to waive the coinsurance for the colonoscopy with removal of tumors, 
polyps or other lesions (45385) provided on January 31, 2022. 
 
You asked the Plan to waive the coinsurance for the colonoscopy. You say that you have never had to pay for a 
colonoscopy, and this was a preventative service. The Plan denied your request. The Plan says this claim was 
processed correctly, and your share of the cost was processed in accordance with your contract. 
 
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 says that there is a $450 deductible 
which applies to outpatient surgery. The contract also clearly says that you must pay 10% coinsurance for 
outpatient surgery.  You have been asked to pay 455.41 for the colonoscopy. The colonoscopy in this case was billed with code 
45385 which classifies it as a surgical procedure which included the removal of tumors, polyps or other lesions. 
This service was not billed as a screening. The medical records also support that a polyp was removed during 
the course of this colonoscopy, which means that the procedure received was diagnostic rather than a screening 
and was billed appropriately. This means that the colonoscopy falls within the outpatient surgery benefit 
category.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $450 deductible which 
applies to outpatient surgery. This cost sharing is a contractual obligation which had not been met at the time 
this service was received on January 31, 2022. After the deductible was paid, $54.05 of the Plans discounted 
rate for this service was left to be paid. You are also responsible for 10% coinsurance on this remaining 
amount, which comes to $5.41. 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 colonoscopy with 
removal of tumors, polyps or other lesions (45385) provided on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit provided to the enrollee on October 
4, 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 this is not a covered benefit. 
 
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 a chiropractic office visit provided to the enrollee on October 4, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the group 2 power wheelchair single power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0835) Wheelchair accessory, 
power seating system, tilt only (E1002). 
 
You asked the Plan to pre-approve the power wheelchair and accessory. You say that you have included copies 
of the enrollee's face sheet, medication lists, physician, physical/occupational therapy reports and recent 
discharge summary from the latest hospital stay. The Plan denied your request. The Plan says Medicare defines 
DME as appropriate for use in the home. The skilled nursing facility where she lives does not qualify as a home 
in Medicare standards. Medicare will not make separate part B payments for her DME because she lives in a 
skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the power wheelchair and accessory is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve the group 2 power wheelchair single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0835) Wheelchair 
accessory, power seating system, tilt only (E1002).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from January 6, 2021, to January 28, 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 there is no 5 day Minimum Data Set (MDS) assessment provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The records do not show that a valid 5 day MDS assessment was provided for these services. 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 skilled nursing facility (SNF) services provided to the enrollee 
from January 6, 2021, to January 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on November 29, 
2021. 
 
You asked the Plan to pay for the services. You say that you do not understand why this claim did not pay. The 
Plan denied your request. The Plan says the provider is on the Medicare opt-out list. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for radiology 
services provided to the enrollee on November 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on February 9, 
2022. 
 
You asked the Plan to pay for the services. You say that this should bep aid for. The Plan denied your request. 
The Plan says this was not reported correctly. 
 
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 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and this 
claim should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of Vertiflex Superion device 
(22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that you strongly believe that coverage should 
be provided. By not providing coverage, this Plan is out of compliance with Medicare guidelines. The Plan 
denied your request. The Plan says there are not enough studies on Vertiflex Superion to show it is safe and 
effective and published studies do not demonstrate long term health outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the surgical placement of Vertiflex Superion device (22869).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat bariatric surgery (43644). 
 
You asked the Plan to pre-approve the bariatric surgery. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says repeat bariatric surgery is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat bariatric surgery is generally not reasonable 
and necessary. Medicare does not provide prior authorization for these services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the bariatric surgery. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found conversion to gastric bypass has 
reported short term weight loss, but has not been shown to result in durable long term weight loss in published 
studies. This patient reported some maladaptive eating behaviors, poor food choices, and lack of activity. It 
would be reasonable to consider other treatments given the lack of clear durable weight loss outcomes from 
sleeve to gastric bypass conversion. 
 
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 bariatric surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve repeat bariatric surgery (43644).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81223, 81227, 81225, 81226) provided January 
12, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single testing panel. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81223, 81227, 81225, 81226) 
provided January 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, hips, bilateral provided on 
October 16, 2021. 
 
You asked the Plan to pay for radiologic examination, hips, bilateral. The Plan denied your request. The Plan 
says the services rendered were not urgent or emergent and there is no prior authorization on file or a referral 
from an in-network 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 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 radiologic examination, hips, bilateral provided on 
October 16, 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 you cannot go home without having additional 
therapy care. The Plan denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received from February 28, 2022, to 
March 1, 2022. 
 
You asked the Plan to pay for the drugs. You say that this should be paid for. The Plan denied your request. 
The Plan says the code for these drugs is not paid under any Medicare payment system. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
from February 28, 2022, to March 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an aortic valve replacement procedure 
performed on January 24, 2022. 
 
You asked the Plan to waive the deductible for the valve replacement. You say that you were supposed to have 
the procedure in December and you had met your deductible for 2021. The Plan denied your request. The Plan 
says the correct amount was applied to your deductible. 
 
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 $1,000 deductible which applies certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,000 
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the valve replacement was received on January 24, 2022. Please note that once the 
deductible was met, you were not charged the applicable $295 copayment for the procedure. Therefore, we 
decided that the Plan does not have to waive the deductible for an aortic valve replacement procedure 
performed on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical 
x-ray (D0220), additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), and prophylaxis 
(D1110) provided on January 27, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation, intraoral periapical x-rays, bitewing x-rays, and 
prophylaxis. You say that the dentist office has always been in-network, and you have not had any previous 
issues with payments. The Plan denied your request. The Plan says these services were rendered by a non-
contracted dental provider. The Plan also says that you did not contact the Plan prior to receipt of these 
services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation (D0120), first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), 
bitewing x-rays (D0274), and prophylaxis (D1110) provided on January 27, 2022 by an out-of-network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral transforaminal epidural steroid injections. 
 
You asked the Plan to pre-approve bilateral transforaminal epidural steroid injections. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that injection services are only covered for certain 
indications. 
 
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 bilateral transforaminal epidural steroid 
injections. Our reviewer says that the documentation does not support that the requested services are medically 
reasonable or necessary. Our physician reviewer found you have chronic low back pain. The provided records 
do not document at least 50% of sustained improvement in pain relief and/or improvement in function 
measured from baseline using the SAME scale for at least three months from the prior injections. Therefore, 
you do not meet criteria for the requested 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 bilateral transforaminal epidural steroid injections have not been met. 
Therefore, we decided that the Plan does not have to pre-approve bilateral transforaminal epidural steroid 
injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on April 6, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the services should be covered 
as you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as 
they were non-emergent and 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 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 subsequent nursing facility care (99308) provided 
on April 6, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G assist orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that please see the attached documentation to 
assist in the decision making process for the requested prior authorization with GAP exception. The Plan 
denied your request. The Plan says this item is considered experimental and investigational. There is 
insufficient evidence of its effectiveness. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G assist orthotic device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on March 16, 2022. 
 
  You asked the Plan to pay for the eye refraction. You say that you received a referral from your primary care 
provider to see this treating provider because the Plan has no Plan approved doctors within your service area. 
The Plan denied your request. The Plan says this service is not a covered benefit because it was performed with 
a medical diagnosis. The Plan also says that you were seen for a diagnosis of Macula scars of posterior pole 
(post-inflammatory) (post-traumatic), right eye for the eye refraction. 
 
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 the eye refractions are performed during a routine exam. 
 
We looked at the file and the Plan's rules. The record shows that the eye refraction was performed with a 
medical diagnosis. Based on this information, we decided that the Plan's rules for coverage of the eye refraction 
have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) 
provided on March 16, 2022.