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

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered with insufficient updated medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation can be covered if 
Medicare criteria have been met. 
 
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 Synvisc. Our reviewer says that 
Synvisc is not considered medically reasonable and necessary in this case. You have received several 
injections, but there is not a consistent standard that measures effectiveness of relief. In addition, there is no 
mention as to whether physical therapy or a home exercise program has ever been implemented. It is noted that 
Ibuprofen does provide a small relief and cortisone injections provided short-term pain relief (duration not 
documented). Per the submitted medical records, you have only had one recent visit in the last year. Our 
physician reviewer found that your condition does not meet Medicare criteria for Synvisc. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 20, 
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 provider did not bill as required by Medicare coding regulations. 
 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 76705 
is a column II code to column I code 93976. 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 October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on July 20, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the place of 
service is invalid. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The records show that the enrollee was received custodial care at the time 
the services were provided. The claim billed a place of service as a skilled nursing facility. Based on this 
information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the podiatry services provided on July 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve PT with an OON provider. You say that you need to see this provider. The 
Plan denied your request. The Plan says the services are not covered by an out-of-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 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 
physical therapy (PT) to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
brain provided on October 12, 2021. 
 
You asked the Plan to waive the copayment for an MRI of the brain. You say that when you went to the follow 
up appointment the doctor asked why your husband had an MRI done when he needed to have a positron 
emission tomography (PET)scan done. You also say that you should not have to pay for the wrong test being 
ordered. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $200 copayment after the deductible is met for advanced imaging services.  
 
 The records show your husband did have the brain MRI. The enrollee has been asked to pay a $200 copayment 
for an MRI of the brain. An MRI of the brain falls within the Outpatient Hospital Services benefit category. 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
brain provided on October 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 3-dimensional (3-D) rendering with interpretation of 
computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality (76377) 
provided on December 14, 2020. 
 
You asked the Plan to pay for a 3-D rendering with interpretation. You say that the requested service was a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for 
payment for the requested service have not been met.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 76377 is not supported in the medical record. Specifically, the governing LCA includes 
a list of secondary diagnosis codes which are required to support the medical necessity of CPT code 76377. 
This claim has not been billed with an appropriate secondary diagnosis code. Based on this information, we 
decided that Medicare rules for coverage of a 3-D rendering with interpretation have not been met. Therefore, 
we decided that the Plan does not have to pay for a 3-dimensional (3-D) rendering with interpretation of 
computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality (76377) 
provided on December 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the viral panel testing provided on August 19, 2021. 
 
You asked the Plan to pay for the testing services. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says the services are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The file shows that infectious agent detection by nucleic acid testing was provided due to exposure to COVID-
19. We find that the testing is not supported. The multi-pathogen panel appears to be blanket testing and not for 
a specific diagnosis. Based on this information, we decided that Medicare rules for coverage of the testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the viral panel testing 
provided on August 19, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued skilled nursing facility (SNF) services provided to 
the enrollee from September 5, 2021, to October 4, 2021. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there were no required skilled nursing needs which would be considered skilled services 
by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee did not have any parental 
medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and 
improved; however, her functional improvement had plateaued by 9/5/2021 and she did not require any further 
inpatient skilled rehab services. The enrollees function was at or near her prior level of function and she could 
be discharged to a lower level of care for further services. As of 9/5/2021 the enrollee required custodial 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for continued skilled nursing facility (SNF) services provided to the enrollee from September 5, 
2021, to October 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services (procedure code 62324) provided to the 
enrollee on May 5, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the medical records received do not support that the procedure or service was distinct or 
independent from other services performed. 
 
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.   
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
procedure report does not include documentation of an injection, including indwelling catheter placement to 
verify procedure has been 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 injection services (procedure code 62324) provided to the enrollee on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cochlear implant batteries provided on September 28, 
2021. 
 
You asked the Plan to pay for the cochlear implant batteries. You say that the item should be covered. The Plan 
denied your request. The Plan says you obtained the durable medical equipment from a provider who is not 
certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 
 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the cochlear implant batteries provided 
on September 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for a total hip replacement surgery and 
therapy visits provided from November 1, 2021, to November 2, 2021. 
 
You asked the Plan to reduce the cost sharing for a total hip replacement surgery and physical therapy. You say 
that you were told once you reached over 24 hours in the hospital you would be automatically admitted as an 
inpatient. You also say you should have to pay a $395 copayment for an inpatient procedure. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing 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 20% 
coinsurance for outpatient surgery. Your contract with the Plan also clearly says that you must pay a $40 
copayment for each therapy visit. Your contract also clearly says that unless your provider writes an order to 
admit you as an inpatient, you will be considered outpatient. 
 
The records do not show you were admitted to the hospital as an inpatient. You have been asked to pay 
$2,635.77, which is 20% of the allowed amount for a total hip replacement ($13,178.86 allowed amount x 20% 
coinsurance = $2,635.77). A total hip replacement surgery falls within the Outpatient Surgery, Including 
Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. You 
have been asked to pay the allowed amount of $22.86, which is less than the $40 copayment for a physical 
therapy visit. You have also been asked to pay the allowed amount of $22.17, which is less than the $40 
copayment for an occupational therapy visit. Therapy visits fall within the Outpatient Rehabilitation Services 
benefit category. You have been asked to pay a total cost share of $2,680.80 ($2,635.77 coinsurance + $22.86 
copayment + $22.17 copayment = $2,680.80) 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 reduce the cost sharing for a total hip 
replacement surgery and therapy visits provided on November 1, 2021, to November 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided the enrollee only requires short-term additional 
acute care services that can safely be administered at the current facility.  
 The enrollee does not require services at the LTACH that are not already available at the current facility. There 
are no services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract surgery provided on July 8, 2019. 
 
You asked the Plan to pay for cataract surgery. You say that the surgery for your left eye was paid in full, so 
you do not understand why the Plan would deny payment for the right eye. The Plan denied your request. The 
Plan says the denial of additional payment for this claim is correct, because the Plan is not able to pay the 
balance bill of this claim or require the provider to write off this amount.  
The Plan must follow Medicare rules. Medicare rules say that for a non-contracting, original Medicare 
participating provider, neither the Plan nor the enrollee pays for balance billing. Your contract with the Plan 
states that providers who provide covered services are prohibited from balance billing. 
 
We looked at the file and Medicare rules. This provider participates in Medicare but is out-of-network with the 
Plan. As a result, according to Medicare rules neither you nor the Plan is required to pay the balance bill 
amount of this claim. Based on this information, we decided that Medicare rules for coverage of cataract 
surgery have not been met. Therefore, we decided that the Plan does not have to pay for cataract surgery 
provided on July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on September 19, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate 
payment is made. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 99140 is anesthesia complicated by emergency 
conditions (specify) (List separately in addition to code for primary anesthesia procedure). We find that CPT 
code 99140 is a bundled code. When these services are covered, payment for them is subsumed by the payment 
for the services to which they are incident. 
 
The CPT Code Manual definition of code 00731 is anesthesia for upper gastrointestinal endoscopic procedures, 
endoscope introduced proximal to duodenum; not otherwise specified. We find that there are no relative value 
units or payment amounts for this code. It is only used to facilitate the identification of anesthesia services. 
Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on 
September 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on 
October 30, 2021. 
 You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as 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. 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 the Computed tomography (CT) scan (70450) provided on 
October 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diabetic eye exam with retinal photos 
provided on October 4, 2021. 
 
You asked the Plan to waive the copayment for a diabetic eye exam. You say that you were seen for a diabetic 
screening but were billed $40 for the specialist office visit. You also say that you were informed by the 
provider that she is a specialist and does not do screenings. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing 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 $40 
copayment for a specialist visit.  
 The medical records show you have an existing condition, and that your visit was not for a screening exam. 
You have been asked to pay a $40 copayment for a diabetic eye exam. A diabetic eye exam falls within the 
Vison 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 a diabetic eye exam 
provided on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 31, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 31, 
2021.