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

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on October 6, 
2021, to October 9, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hospital care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were provided out-of-network, were not approved in advance, 
and the claim was submitted with errors. 
  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 the subsequent hospital care (99232) provided on 
October 6, 2021, to October 9, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for surgical pathology services provided on May 9, 2022. 
 
You asked the Plan to pay for the surgical pathology services. You say that the specimen was sent directly to 
you by the patient's network physician and your organization does not see the patient. The Plan denied your 
request. The Plan says that unauthorized, non-plan care is not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the surgical pathology services by a podiatrist.  The Plan failed to identify if the 
referring podiatrist is a network doctor or not in the case file it sent to us.  The referring podiatrist does appear 
on the Plan's website as a network provider.  In addition, you have alleged that the referring provider is a 
network provider.  Due to the Plan's failure to dispute this assertion in its case file submission, we must assume 
that the referring provider is indeed a network, contract doctor. By sending the patient's specimen to you, this 
network contract doctor approved this service. Under Medicare rules, this means the surgical pathology 
services are considered approved by the plan. Therefore, we decided that the Plan has to pay for surgical 
pathology services provided on May 9, 2022.  
 
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: Transportation
Decision: Favorable

 
We decided that the Plan has to waive the copayment for ambulance services provided on January 19, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this transport was needed 
as a result of COVID-19, so the copayment should be waived. The Plan denied your request. The Plan says that 
it charged a $225 ambulance copayment because there was no COVID-19 related diagnosis billed with the 
ambulance services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The 
Plans own website explicitly states the following: there is no copay or prior authorization required for 
ambulance trips related to COVID-19.  The Plans sole rationale for the application of this copayment is that 
the provider didnt bill with a COVID-19 diagnosis.  However, this simply is not correct.  The claim in the case 
file that the Plan submitted to us was billed with diagnosis code J12.82.  The definition of this diagnosis code is 
Pneumonia due to coronavirus disease.  So, clearly, this transport was provided in relation to a COVID-19-
related condition.  It is the Plans obligation to provide enough evidence to support its application of cost 
sharing, and we find that the Plan has failed to do so in this case. Therefore, we decided that the Plan has to 
waive the copayment for ambulance services provided on January 19, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ostomy supplies you received on March 3, 
2022. 
 
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that you have never had to pay 
anything for these supplies in the past since they were under the home nurse program. The Plan denied your 
request. The Plan says you were charged this cost sharing correctly.  The Plan says that these supplies were not 
billed by the home nurse program, but by a separate provider. 
 
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 prosthetic devices and related supplies.  
 
You have been asked to pay 20% coinsurance for the ostomy supplies. The ostomy supplies fall within the 
prosthetic devices and related 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 coinsurance for 
ostomy supplies you received on March 3, 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 requires IRF in effort to facilitate 
increased independence and return home with improved quality of life. The Plan denied your request. The Plan 
says the enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 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. There is not a reasonable expectation that 
this individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. 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 the enrollee 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the burning sensation in 
your arms and hands is very painful and you are unable to sleep. You say that physical therapy is helping, and 
additional visits can get you back to 100%. The Plan denied your request. The Plan says 10 additional visits are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 10 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that you have previously been treated 
with outpatient therapy and should be independent with a home exercise program. Additional therapy services 
are not an appropriate treatment for your medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computerized corneal topography you 
received in an ophthalmologist's office on April 18, 2022. 
 
You asked the Plan to waive the copayment for the computerized corneal topography. You say that this service 
was related to your recent cataract surgery, so the claim should be paid in full. The Plan denied your request. 
The Plan says this claim was not denied, but you have been charged the appropriate copayment 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 $35 
copayment for Medicare-covered vision services in a specialist's office.  
 
You have been asked to pay a $35 copayment for the computerized corneal topography. The computerized 
corneal topography falls within the Medicare-covered vision services in a specialist's office 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 computerized corneal topography you received in an 
ophthalmologist's office on April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on January 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
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 the lab testing provided on January 25, 2022, by 
an out-of-network (OON) provider.
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. The Plan denied your request. The Plan says you do not meet the 
requirements for coverage. 
 
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 do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. You 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 you would meet 
criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you 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 her functional status. You 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam you had on October 21, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you went in for a routine eye exam, 
so there should be no copayment. The Plan denied your request. The Plan says you were charged this 
copayment 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 $35 
copayment for Medicare-covered vision care.  
 
You have been asked to pay a $35 copayment for the eye exam. The medical records show that this was not a 
routine eye exam, but a diabetic eye exam.  Diabetic eye exams are Medicare-covered eye exams and do not 
fall in the routine eye exam 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 eye exam you 
had on October 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $250 copayment charged for a computed tomography scan 
provided on February 22, 2022. 
 
You asked the Plan to waive this cost share. You say that you do not believe you owe this copayment. The Plan 
denied your request. The Plan says this copayment is a contractual obligation. 
 
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 $150 
copayment for outpatient imaging services. 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 $250 copayment charged for a computed 
tomography scan provided on February 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93313-59 billed for date of service March 16, 
2022. 
 
You asked the Plan to pay for procedure code 93313-59. You say that the TEE was placed at the surgeon's 
request and should be paid. The Plan denied your request. The Plan says code 93313-59 is not supported in the 
medical record because the records do not show that it 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 procedure code 93313-59 Our reviewer says 
that separate payment for this code is not supported. Our physician reviewer found the anesthesia report 
describes a transesophageal echocardiograph (TEE) was performed for intraoperative monitoring purposes 
only.  In this case, probe placement may not be billed separately. The operative report documents "Procedure: 
CABG X4; Left IMA; Left EVH; TEE (N/A Chest)".  In this case, CPT 93313 cannot be verified as a separate 
procedure from the anesthesia 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 procedure code 93313-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 93313-59 billed for date of service March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital observation services 
provided from May 2, 2022, to May 4, 2022, and the electrocardiogram (ECG) provided on May 10, 2022. 
 
You asked the Plan to waive the copayment for the observation services and the ECG. You say that these 
services should be fully covered. 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 $225 
copayment for outpatient hospital observation services. Your contract also says that you must pay a $30 
copayment for the ECG.  
 
You have been asked to pay a $225 copayment for the observation services from May 2, 2022, to May 4, 2022. Please note that tests received while under observation were included in the single copayment for the 
observation stay. The observation services fall within the Outpatient Hospital Observation benefit category. 
You have also been asked to pay a $30 copayment for the ECG provided on May 10, 2022. The ECG 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 outpatient hospital observation services provided from May 2, 2022, 
to May 4, 2022, and the electrocardiogram (ECG) provided on May 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital services provided from April 4, 
2022, to April 5, 2022. 
 
You asked the Plan to waive the copayment for the hospital services. You say that you were not given a room 
during your stay, and you did not have a scope done. You say you do not know if you were considered 
inpatient, outpatient, or under emergency services. 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 $200 
copayment for outpatient hospital observation services.  
 
The Plan has approved your stay as an outpatient observation stay. You have been asked to pay a $200 
copayment for the hospital services. The outpatient observation hospital services fall within the Outpatient 
Hospital Observation 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 hospital 
services provided from April 4, 2022, to April 5, 2022.  
 
Please note, the Plan has confirmed that you are no longer being charged the $90 copayment for the emergency 
room visit on April 3, 2022.