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

 
We decided that the Plan does not have to pay for surgical services (procedure code 36556) provided to the 
enrollee on April 21, 2022. 
 
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 CPT 93503 may not be reported with CPT 36556. 
 
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 36556 is "Insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older." 
 
We asked our coder 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 reviewer found that in this case, CPT 36556 is not 
allowable with CPT 93503.  
 
We looked at this coder'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 surgical services (procedure code 36556) provided to the enrollee on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for the diagnostic retinal imaging and eye 
injections provided from January 14, 2022, to March 25, 2022. 
 
You asked the Plan to reduce the cost sharing for the imaging and eye injections. You say that the charges are 
the same as last year, but your responsibility has increased. 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 $175 
copayment for each diagnostic procedure and test. Your contract also says you must pay a $315 copayment for each outpatient surgery. Your contract also say that you must pay 20% coinsurance for Part B drugs. 
 
You have been asked to pay the following for the imaging and eye injections. 
 
Date of Service Procedure 
Code 
Allowed Amount 20% 
Coinsurance 
Copayment 
January 14, 2022 92134 $39.40  $39.40 (less than the $175 
copayment) 
 67028 $109.29  $109.29 (less than the $315 
copayment) 
 J0178 $1835.88 $367.18  
     
February 18, 2022 92134 $39.08  $39.08 (less than the $175 
copayment) 
 67028 $109.29  $109.29 (less than the $315 
copayment) 
 J0178 $1831.50 $366.30  
     
March 25, 2022 92134 $39.08  $39.08 (less than the $175 
copayment) 
 67028 $109.29  $109.29 (less than the $315 
copayment) 
 J0178 $1831.50 $366.30  
 
The imaging falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. The injection of the drug falls within the Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers benefit category. The drug injected falls within the 
Medicare Part B Prescription Drugs 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 reduce the cost sharing for 
the diagnostic retinal imaging and eye injections provided from January 14, 2022, to March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the urgent care visit provided on May 4, 
2022. 
 
You asked the Plan to reduce the copayment for the urgent care visit. You say that your primary care physician 
was not available, and you were directed to go to urgent care. You say that you were told the visit would have a 
$15 copayment, but you were billed a $30 copayment. The Plan denied your request. The Plan says the 
copayment applied 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 $30 for 
each Medicare-covered urgent care facility visit.  
  You have been asked to pay a $30 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently Needed Services benefit category. The records show that you were seen at an urgent care facility. 
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 copayment for the urgent care visit provided on May 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on May 5, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you think insurance is responsible 
for the balance because of the estimate you were given by your provider. 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 $165 
copayment for radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay $141.85, which is less than the $165 copayment for the ultrasound. The ultrasound 
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 the ultrasound provided on May 5, 2022.
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 inpatient rehabilitation care. The 
Plan denied your request. The Plan says the criteria for admission to an IRF are not met in this case; the 
enrollee can safely be treated in a lower level of care. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee does continue to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement; however, the documentation 
does not support that the criteria for admission to an acute inpatient rehabilitation facility are met. There is no 
indication that the enrollee would require skilled rehabilitation in an IRF, with a minimum of 15 hours of 
rehabilitation therapies per week, under the supervision of a physician with at least three visits weekly to regain 
or maintain functional status. The enrollee can receive the necessary services at a lower level of care. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 screening (U0003) provided on March 14, 
2022, so that you could re-enter the United States. 
 
You asked the Plan to pay for the COVID-19 screening. You say that your plan covers laboratory services, and 
this test was necessary for you to return to the United States. The Plan denied your request. The Plan says 
Medicare covers services provided outside of the United States only in cases where the services were emergent 
and medically necessary. A COVID-19 screening test provided for travel purposes is neither medically 
necessary nor emergent. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 screening have not been met. Specifically, this service was provided in a foreign 
country for the purpose of travel and was not provided for the diagnosis and treatment of an illness or injury. In addition, this service was not urgent or emergent medical care. Therefore, we decided that the Plan does not 
have to pay for the COVID-19 screening (U0003) provided on March 14, 2022, so that you could re-enter the 
United States.
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 this is medically necessary. The Plan denied your 
request. The Plan says this is 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 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 that in this case, the complexity of the members nursing, medical and rehabilitation 
needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for 
skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation doesnt support that he would meet criteria for admission to an acute inpatient rehabilitation 
facility. There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in 
rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain his functional status. The enrollee can receive further services at a lower level of care. 
 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasonic guidance provided to the enrollee on March 8, 
2022. 
 
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 code is inclusive to another code. 
 
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 76998 is "Ultrasonic guidance, intraoperative." 
 
We asked our coder 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 reviewer found that the operative report describes 
ultrasound was used to locate the tumor for excision.  Operative report documents "We used ultrasound at this 
time to identify the location of our tumor, and noted that it was adequately exposed underneath our bony 
exposure." In this case, this procedure would be inclusive to the tumor excision and not reported separately. 
 We looked at this coder'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 ultrasonic guidance provided to the enrollee on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair van transport you received on February 17. 
2021. 
 
You asked the Plan to pay for the wheelchair van transport. You say that this service should be covered 
because it was caused by you being sick with COVID-19. The Plan denied your request. The Plan says this 
service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services. Your Plan says that it will only cover non-ambulance transport (such as wheelchair van transport) 
when going from a hospital to a SNF. 
 
The services you have asked the Plan to pay for are wheelchair van transport services. You were not 
transported from a hospital to a SNF.  Rather, you were transported from a SNF to your home.  Neither 
Medicare nor the Plan covers wheelchair van services for this purpose. This non-coverage rule applies even to 
services related to a COVID-19 diagnosis. However, the provider of this service didnt bill with a COVID-19-related diagnosis. Therefore, we decided that the Plan does not have to pay for the wheelchair van transport you 
received on February 17. 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor (CGM) supplies (K0553) 
provided on November 10, 2021. 
 
You asked the Plan to pay for the CGM supplies. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 8, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for continuous glucose monitor (CGM) supplies 
(K0553) provided on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses and an eye exam provided on May 6, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for eyeglasses and an eye exam. You say that you would like assistance with paying 
for the eyeglasses and eye exam. The Plan denied your request. The Plan says you had the eye exam and 
received the eyeglasses from an out-of-network provider.  Out-of-network services are not covered under your 
Plan. 
 
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 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 eyeglasses and an eye exam provided on May 6, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the urology visit and the pelvic ultrasound 
you had on April 5, 2022. 
 
You asked the Plan to waive the cost sharing for the urology visit and the pelvic ultrasound. You say that you 
don't agree with the amount the Plan paid on this claim. The Plan denied your request. The Plan says you were 
charged this cost sharing correctly.  The Plan says that for the ultrasound, the allowed amount for this service 
($78.38) is less than your copayment obligation, so you are responsible for the full amount for this service. 
 
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 $120 
copayment for radiological diagnostic services. Your contract also says that you pay a $35 copayment for visits 
with a specialist. 
 
You have been asked to pay a $120 copayment for the pelvic ultrasound and a $35 copayment for the urology 
visit. The pelvic ultrasound falls within the radiological diagnostic services benefit category.  Because the allowed amount for this service is less than the $120 copayment, you are responsible for the full allowed 
amount of $78.38.  In addition, a urologist is a specialist, so the specialist visit copayment also applies.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 cost sharing for the urology visit and the pelvic ultrasound you had on 
April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the wound debridement procedures you 
had at an outpatient hospital facility from February 21, 2022, to March 21, 2022. 
 
You asked the Plan to waive the copayments for the wound debridement procedures. You say that these 
services should have had a $35 copayment per visit.  You said that you were never told at the time of each visit 
that you would have to pay a higher amount. The Plan denied your request. The Plan says you were charged 
these copayments correctly. The Plan says that because the allowed amount for each date of service is less than 
your copayment obligation, you are responsible for the full allowed 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 $350 
copayment per date of service for outpatient surgery and services at an outpatient hospital facility.  
 
You have been asked to pay a $350 copayment per date of service for the wound debridement procedures. 
Wound debridement is considered a surgical service.  In addition, records show that these services were performed in and billed by an outpatient hospital facility, not a specialist. 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 copayments for the wound debridement procedures you had at an outpatient hospital facility from February 
21, 2022, to March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the referring provider sent the specimen to you and 
your lab did not physically see the patient. 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. 
 
The provider in this case is not a network provider with the Plan. We have also confirmed that the referring 
provider on the claim is not a network provider with the Plan via the Plan's online provider directory. 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 lab services provided on 
April 25, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the yoga class provided on March 25, 2022. 
 
You asked the Plan to pay for the yoga class. You say that you should be reimbursed because it took the Plan 
two months to send a denial to you for the service. The Plan denied your request. The Plan says you did not 
provide proof of payment for the yoga class. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only if a Wellness Allowance reimbursement form along with proof of payment and any additional information 
outlined on the form is sent to the Plan. 
 
The Plans rules for coverage of gym benefits have not been met because you did not provide proof of payment 
for the yoga class. Therefore, we decided that the Plan does not have to pay for the yoga class provided on 
March 25, 2022.