Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
does not require transfer to an LTACH. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. All medically necessary care is being provided in the current acute care setting. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on March 9, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
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 outpatient mental 
health services provided on March 9, 2022, 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 PET scan provided on January 24, 2022. 
 
You asked the Plan to waive the copayment for a PET scan. You say that you were unaware of this copayment 
and therefore would like it waived. The Plan denied your request. The Plan says the copayment applied was 
correct. 
 
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 for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay a $350 copayment for a PET scan. A PET scan falls within the Medicare-Covered 
Diagnostic Radiology Services 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 
positron emission tomography (PET) scan provided on January 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are 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 a spinal cord stimulator. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found you do not have an evidence-based indication for a spinal cord stimulator trial. The request is deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound (76641) provided on April 22, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that a mammogram is a preventive service. You say that 
you require an ultrasound. You say that you feel this should be covered as preventive. You also say that you 
cannot get a full reading unless you have an ultrasound. The Plan denied your request. The Plan says the 
copayment was 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 a $40 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $40 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 pay for 
the ultrasound (76641) provided on April 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from March 2, 
2022, to March 17, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you are not going to pay for this 
copayment. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $290 
copayment for days 1 to 4 for in-network inpatient care ($290 x 4 days = $1160).  
 
You have been asked to pay a $1160 copayment for days 1 to 4 for an inpatient stay. An inpatient stay falls 
within the In-Network Inpatient Care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an inpatient stay provided from March 2, 2022, to March 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
March 10, 2022, to March 13, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you are on a limited income 
and cannot afford the copayment. 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 $300 
copayment for each inpatient admission, up to a yearly maximum of $900.  
 
You have been asked to pay a $300 copayment for the inpatient care. The inpatient care falls 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 inpatient 
hospital care provided from March 10, 2022, to March 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 16, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on November 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous positive airway pressure (CPAP) device (E0601) 
and DME delivery, set up, and/or dispensing service (A9901) purchased January 6, 2022. 
 
You asked the Plan to pay for the CPAP device and shipping fee. You say that your doctor recommended a 
breathing device such as a CPAP. You have COPD and is diabetic and you feel this claim should not be denied. 
The Plan denied your request. The Plan says the durable medical equipment was purchased from a supplier that 
is not certified with Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be 
responsible for the full cost of the services you receive. 
 
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 continuous positive airway pressure 
(CPAP) device (E0601) and DME delivery, set up, and/or dispensing service (A9901) purchased January 6, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 24, 2022, 
through February 22, 2022. 
 You asked the Plan to pay for the home health services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that effective on or after January 1, 2022, home 
health services will be billed via submission of an NOA with Type of Bill 032A.  
 
We looked at the file and Medicare rules. In this case, the claim has not been submitted with a Type of Bill 
032A for an NOA. Based on this information, we decided that Medicare rules for coverage of the home health 
services have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services provided from January 24, 2022, through February 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 23, 2022, 
through February 28, 2022. 
 You asked the Plan to pay for the home health services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the services have not been billed as 
required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that effective on or after January 1, 2022, home 
health services will be billed via submission of an NOA with Type of Bill 032A. 
 
We looked at the file and Medicare rules. In this case, the claim has not been submitted with a Type of Bill 
032A for an NOA. Based on this information, we decided that Medicare rules for coverage of the home health 
services have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services provided from February 23, 2022, through February 28, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal cord stimulator implant trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator implant trial. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are 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 a spinal cord stimulator implant trial. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the request 
meets all of the NCD criteria. The request is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a spinal cord stimulator implant trial have been met. Therefore, we decided that 
the Plan has to pre-approve a spinal cord stimulator implant trial.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laparoscopic cholecystectomy (L47592) and repair umbilical 
hernia (49585) provided June 29, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the provider is a Certified Registered Nurse 
First Assistant and according to Texas Law the submitted services undeniably fall within the scope of her 
provider license. Her services are that of an assistant surgeon. The Plan denied your request. The Plan says the 
services billed outside of scope of provider. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. the records indicate that the services were performed by a Certified Registered Nurse First 
Assistant. Although skilled, a registered nurse first assistant RNFA, is not eligible for reimbursement, as 
outlined in state guidelines and licensure. Per CMS claims processing manual guidelines, surgical technicians 
are not listed as a health care practitioner that can report modifier AS. The services of a surgical technician 
assisting at surgery are included in the reimbursement to the facility and not separately reimbursable Therefore, 
we decided that the Plan does not have to pay for laparoscopic cholecystectomy (L47592) and repair umbilical 
hernia (49585) provided June 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening lipid panel (80061, 83036, 85025) provided on 
February 14, 2022. 
 
You asked the Plan to pay for a screening lipid panel. You say that this is a preventative measure and should be 
covered. The Plan denied your request. The Plan says this is not a covered screening service. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a screening lipid panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for a screening lipid panel (80061, 83036, 85025) provided on February 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service January 20, 
2022. 
 
You asked the Plan to pay for procedure code 99291. You say that 99291 is being bundled incorrectly to 
36556, which was performed by a different provider. The Plan denied your request. The Plan says payment for 
code 99291 is bundled into payment for code 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, we have confirmed that code 99291 
is a column II code to column I code 36556. In addition, we have confirmed that both claims were submitted 
with the same providers name and identification number. 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 procedure code 99291 billed for date of service 
January 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a TTE provided on April 25, 2022. 
 
You asked the Plan to waive the copayment for a TEE. You say that you should not have this copayment. The 
Plan denied your request. The Plan says the copayment applied was correct. 
 
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 a Freestanding Radiological Facility.  
 
You have been asked to pay a $50 copayment for a TEE. A TEE falls within the Freestanding Radiological 
Facility 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 Transthoracic 
Echocardiography (TTE) provided on April 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood glucose assay quantity, routine venipuncture and 
outpatient hospital clinic visit billed on the inpatient claim for June 24, 2021, through August 11, 2021. 
 
You asked the Plan to pay for the blood glucose assay quantity, routine venipuncture and outpatient hospital 
clinic visit. You say that you would like reconsideration based on the records submitted. The Plan denied your 
request. The Plan says these services are not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that included in routine services are the regular room, 
dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social 
services, and the use of certain equipment and facilities for which a separate charge is not customarily made.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the blood glucose assay quantity, routine venipuncture and outpatient hospital clinic visit have not 
been met. Specifically, the blood glucose assay quantity and routine venipuncture are considered routine 
services and bundled with the room and board or procedure charge. Additionally, separate payment is not made 
for the outpatient hospital clinic visit as payment is included in the Part A payment. Therefore, we decided that 
the Plan does not have to pay for the blood glucose assay quantity, routine venipuncture and outpatient hospital 
clinic visit billed on the inpatient claim for June 24, 2021, through August 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71260 billed for date of service March 21, 
2022. 
 
You asked the Plan to pay for procedure code 71260. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 71260 is bundled into payment for 
code 71275. 
 
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 71260 
is a column II code to column I code 71275. 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 procedure code 71260 billed for date of service March 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 24, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 procedure code 70450 billed for date of service March 24, 2022.