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

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
September 27, 2021, to September 29, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says it has been determined that outpatient services were delivered, not 
acute inpatient services. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the review has determined that the record did not show that at the time of 
inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. The records do not show that actual 
inpatient services were provided on these dates. It appears that outpatient services were provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee from September 27, 2021, to 
September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 13, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 13, 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 June 25, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 June 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 29, 2022. 
 
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. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. We find that the code was not billed with a modifier suitable for payment. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
March 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Electrocardiogram (ECG) provided on 
November 11, 2021. 
 
You asked the Plan to waive the copayment for an ECG. You say that you paid a $40 copayment for the office 
visit so you shouldn't have to pay the additional copayment. The Plan denied your request. The Plan says this 
cost sharing was charged 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 $20 
copayment for outpatient diagnostic tests/Medicare covered non-radiological diagnostic services. 
 
You have been asked to pay a $20 copayment for an ECG. However, you are only being asked to pay $13.32 
which is less than the required amount. 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 
Electrocardiogram (ECG) provided on November 11, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on February 1, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
provided on February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve surgery. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says in order to consider approval of an INN 
request the Out-of-Network Provider must possess unique skills which are required to adequately care for the 
member and are not available from Network Providers. This provider and/or facility does not meet this 
criteria based on the information provided. 
 
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 
surgery to be provided 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 anti-reflective coating (V2750), progressive lens 
(V2781), and hi-index lens (V2783) provided on June 21, 2022. 
 
You asked the Plan to pay for the anti-reflective coating, progressive lens, and hi-index lens. You say that your 
glasses broke, and you needed to be replaced as soon as possible. The Plan denied your request. The Plan says 
you have exceeded the limits set in the subscriber agreement. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once every two years. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that the Plan issued payment for the 
lenses you received on March 2, 2021, and there is not a two-year gap between March 2, 2021, and June 21, 
2022. Based on this information, we decided that the Plan's rules for coverage of the anti-reflective coating, 
progressive lens, and hi-index lens have not been met. Therefore, we decided that the Plan does not have to pay 
for the anti-reflective coating (V2750), progressive lens (V2781), and hi-index lens (V2783) provided on June 
21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pre-approve an Intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Intracept procedure is experimental. More research is needed to demonstrate the safety 
and effectiveness of the procedure. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator. 
 
You asked the Plan to pre-approve a osteogenesis stimulator. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
 
 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 an osteogenesis stimulator. Our 
reviewer says that the documentation does not support that the requested device is medically reasonable or 
necessary. Our physician reviewer found you were being treated for unspecified fracture of right foot, 
subsequent encounter for fracture with nonunion. You presented greater than 12 weeks status post right foot 
Austin bunionectomy of the first toe, Akin osteotomy with second toe PIP (proximal interphalangeal) joint 
implant, arthrodesis with pinning. You are walking with the aid of a cane. The detailed documentation is not 
evident regarding a failed fusion with serial radiographs where a minimum of nine months has elapsed since 
the surgery. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. Therefore, you do not meet criteria for the 
requested device. 
 
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 osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on January 04, 2022, to 
February 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says as a member of our plan, the enrollee must use network providers. If 
the enrollee receives unauthorized care from an out-of-network provider, we may deny coverage and the 
enrollee will be responsible for the entire cost. 
 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 provided on January 04, 
2022, to February 23, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy service (90834) provided on May 12, 
2022. 
 
You asked the Plan to pay for the psychotherapy service. You say that you are on a fixed income. You say that 
you were unaware that you needed pre-approval. You also say that your primary care doctor referred you to 
this provider. The Plan denied your request. The Plan says the provider in this case is not eligible to participate 
in Medicare. The Plan also says payment cannot be made for services performed by a provider that is not 
eligible to participate in 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. Additionally, the record shows that your primary care doctor is not a Medicare provider either. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy service (90834) provided on 
May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 4, 
2021. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 5, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 July 5, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429) and ground mileage (A0425) provided on November 23, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that this plan is the enrollee's primary Medicare 
plan. You also say that it should be processed that way. The Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits 
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it 
is the providers responsibility to verify the enrollees coverage before rendering services and to know proper 
billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 8, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance 
service, basic life support, emergency transport (A0429) and ground mileage (A0425) provided on November 
23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services. 
 
You asked the Plan to pre-approve the physical therapy services. You say that you went to the out-of-network 
provider because you could not see an in-network provider within the time frame your physician advised. You 
say that you want to continue with this provider as you need more sessions and would like them to be covered. 
The Plan denied your request. The Plan says the requested treatment is available with in-network providers. 
 
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 services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (procedure code 83789) provided to the enrollee 
on June 22, 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 there is a more appropriate/accurate code to report for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for lab services (procedure code 83789) provided to the enrollee on June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (DME) purchased on December 
9, 2021, and December 10, 2021. 
 
You asked the Plan to pay for the DME. You say that both of your ankles were broken. The Plan denied your 
request. The Plan says providers who do not participate in Medicare cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program. 
 
The rendering equipment provider is eligible to bill Medicare. Based on this information, we decided that 
Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have 
to pay for durable medical equipment (DME) purchased on December 9, 2021, and December 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the compression stockings identified with 
code A6530 that were purchased on June 14, 2022. 
 
You asked the Plan to issue reimbursement for the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these items are 
not a covered benefit under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 
 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to issue reimbursement for the 
compression stockings identified with code A6530 that were purchased on June 14, 2022.