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

 
We decided that the Plan does not have to waive the copayment for interrogation device evaluations (93297, 
G2066) provided on January 17, 2022. 
 
You asked the Plan to waive the copayment for interrogation device evaluations. You say that your provider 
told you that your insurance would cover these services in full. The Plan denied your request. The Plan says 
this claim was processed correctly, and your copayment was assessed in accordance with your contract. 
 
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 $45 
copayment for each Medicare-covered diagnostic procedure and test.  
 
You have been asked to pay a $45 copayment for interrogation device evaluations. An interrogation device 
evaluation falls within the Medicare-covered diagnostic procedure and test 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 interrogation device evaluations (93297, G2066) provided on 
January 17, 2022.  Your complaint about possible misinformation from a Plan-contracted provider is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance angiography (MRA) of the head 
provided to the enrollee on October 31, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the magnetic resonance imaging (MRI) and the MRA were both performed during the same 
patient encounter. 
 
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 70546 is "Magnetic resonance angiography, head; 
without contrast material(s), followed by contrast material(s) and further sequences." 
 
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 provider reported MRA and 
MRI on the same date of service, with one report. In this case, CPT 70546 would be inclusive to the MRI, as 
two full separate reports were not included. Therefore, modifier -59 cannot be verified. 
 
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 magnetic resonance angiography (MRA) of the head provided to the enrollee on October 31, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the various services (procedure codes 36245, 36246, 37222, 
76000) provided to the enrollee on September 14, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
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 the denied codes is: 
 
CPT 36245: 
 
Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery 
branch, within a vascular family 
 
CPT 36246: 
 Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery 
branch, within a vascular family 
 
CPT 37222: 
 
Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with 
transluminal angioplasty (List separately in addition to code for primary procedure) 
 
CPT 76000: 
 
Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time 
 
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 does include 
enough documentation to confirm that these denied procedures were rendered. 
 
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 the various services (procedure codes 36245, 36246, 37222, 76000) provided to the enrollee on 
September 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transthoracic echocardiogram (TTE) with 
doppler provided on March 2, 2022. 
 
You asked the Plan to waive the copayment for the TTE with doppler. You say that the doctor's office billed 
the claim incorrectly and you should not be charged. 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 $100 
copayment for diagnostic procedures at an outpatient hospital.  
 
The file shows that the billing service location reflects an outpatient hospital facility. Therefore, you have been 
asked to pay a $100 copayment for the TTE with doppler. The TTE with doppler 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 a transthoracic echocardiogram (TTE) with doppler provided on March 2, 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 
September 23, 2020, to October 1, 2020. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you never had a big payment 
for this service before. 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 $300 per 
calendar year for general acute care.  
 
You have been asked to pay $300 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 September 23, 2020, to October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with power 
accessories to be coded as E1399. 
 
You asked the Plan to pre-approve the PWC coded as E1399. You say that this is extremely medically 
necessary and should be approved. The Plan denied your request. The Plan says the supplier is requesting this 
be reimbursed under code E1399 which is not allowed by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers/enrollees must submit sufficient 
evidence to support coverage for requested items. It is noted that code E1399 may be used for certain 
customized items.  
 
We looked at the file and Medicare rules. The Plan attests that the provider is arguing that code E1399 must be approved as all brand-specific and specialty items are to be coded as such based on a contract. However, 
insufficient information was submitted to support that this PWC is to be customized to a point where the 
standard code for this brand is not appropriate. Based on this information, we decided that Medicare rules for 
coverage of the PWC coded as E1399 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Group 3 power wheelchair (PWC) with power accessories to be coded as E1399.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that her physicians and therapists have recommended 
inpatient rehabilitation prior to going home. You say that she requires rehabilitation to facilitate independence 
and authorization should be granted. The Plan denied your request. The Plan says care can be received in 
another setting. 
 
  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 enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray (71101-RT-26) provided on February 25, 2022. 
 
You asked the Plan to pay for the x-ray. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the payment for this x-ray is included in the payment for the emergency department 
visit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
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 x-ray. Our reviewer says that this service is not supported 
for separate payment. Our reviewer found that the x-ray (71101) and emergency department visit (99284) were 
billed together by the same healthcare provider. The medical records include a radiology report for rib 
examination. No documentation of a separate emergency department visit was included, therefore billing 
radiological services as a separate or distinct service cannot be verified. Of note, payment for radiological 
services would not be inclusive to evaluation and management services, however in this case documentation 
does not support services and modifiers billed by the same provider, for the same date of service. 
 
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 x-ray have not been met. Therefore, we decided that the Plan does not have 
to pay for the x-ray (71101-RT-26) provided on February 25, 2022.  
 Please note: the denial of this service does not mean you (the enrollee) are responsible for this portion of the 
bill. The denial of this x-ray is a billing issue and not a medical necessity denial. Your explanation of benefits 
which was processed by the Plan on April 5, 2022, indicates that you are not liable (responsible) for the cost of 
this service. This denial means only that the payment for the x-ray is included in the payment the Plan made for 
the emergency department visit, so the Plan does not owe the provider any additional amount. You do not owe 
money for the x-ray. 
 
If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan 
directly.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says with the information 
we have, we cannot determine how the member came to the servicing provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physicians intent that the tests be performed. 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 the lab 
services provided on February 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional non-emergent transportation trips. 
 
You asked the Plan to provide additional non-emergent transportation trips. You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says the member's 2022 
Evidence of Coverage for clearly states 30 one-way trips per calendar year and the 31st and beyond is not a 
covered benefit. The member has used 24 trips and has 6 trips remaining in 2022. 
 
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 30 trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that once you have exhausted the Plan maximum benefit for coverage of routine transportation the plan does 
not have cover more than the allowed amount that is stated in your EOC. Therefore, we decided that the Plan 
does not have to provide additional non-emergent transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee is not demonstrating a significant decline in the prior level of function. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found that based on 
the medical records provided, there is no documentation that you require skilled nursing services, i.e., the 
specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and 
effectively provide medically necessary and reasonable treatment. The records do not document the need for 
intravenous medications, new tube feeding or ostomy care or daily complex wound care or respiratory 
care. Daily skilled services are not required. Although the records document that the enrollee is very limited 
functionally, the provided records do not document a significant decline in functional status to the recent 
baseline to necessitate daily inpatient skilled therapy services. There is no documentation that you require the 
services on an inpatient basis, only in a skilled nursing facility setting. The records do not document that 
services in an assisted living facility with home health care or in a long-term care facility on a part time basis 
are not appropriate in this case. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are medically cleared for discharge. The Plan 
denied your request. The Plan says you do not meet the criteria for an IRF admission. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services for an eye procedure (00142) provided on October 
26, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that the services at issue were a medical necessity 
for you. The Plan denied your request. The Plan says that rules for payment have not been met because the 
services at issue are included in another billed code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided documentation to support that the 
services at issue are not separately payable. It is the Plan's responsibility to substantiate its denial. In this case, 
the denial has not been substantiated, so we must find in your favor. Therefore, we decided that the Plan has to 
pay for anesthesia services for an eye procedure (00142) provided on October 26, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this treatment is considered safe and 
effective and is medically necessary. The Plan denied your request. The Plan says this device 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 the Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and 
efficacy. 
 
 
  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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from January 20, 2022, to April 11, 2022. 
 
You asked the Plan to waive the copayments for the PT services. You say that you were not aware of the 
copayments. You says that copayments were not mentioned at the times of service. 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 $35 
copayment for each therapy visit.  
 
The file shows you had 28 visits for PT services from January 20, 2022, to April 11, 2022. Therefore, you have 
been asked to pay a $35 copayment for each visit, for a total of $980 ($35 copayment x 28 visits = $980). The 
PT services fall within the Outpatient Rehabilitation 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 copayments for physical therapy (PT) services provided from January 20, 2022, to April 11, 2022.