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

 
We decided that the Plan does not have to pay for an office visit, constant attendance physical medicine and 
rehabilitation modalities, chiropractic treatments to extraspinal regions and electrical stimulation provided from 
April 27, 2022, to May 19, 2022. 
 
You asked the Plan to pay for an office visit, constant attendance physical medicine and rehabilitation 
modalities, chiropractic treatments to extraspinal regions and electrical stimulation. You say that the 
chiropractic services are medically necessary. The Plan denied your request. The Plan says the denied services 
are not covered under the members contract under any normal circumstances. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for an office visit, constant attendance physical medicine and rehabilitation 
modalities, chiropractic treatments to extraspinal regions and electrical stimulation provided from  
April 27, 2022, to May 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like reconsideration because the 
requested SNF services are medically necessary. The Plan denied your request. The Plan says your needs may 
be safely met in a lower level of care. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided there is no documentation that daily skilled 
services are required. There is no documentation that you require the requested services on an inpatient basis, 
only in a skilled nursing facility setting. Records do not support that services in the home 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (ESIs) (64483, 64484). 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the requested injections are not medically reasonable or necessary. 
 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 injections. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee the enrollee responded to a course of physical therapy and continues with a 
home exercise program. There is no evidence of pain severe enough to greatly impact quality of life or 
function. The review has determined that the criteria for coverage have not been met. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve epidural steroid injections (ESIs) (64483, 64484).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share amounts for the operating room services and 
self-administered drugs provided on May 12, 2022, and May 13, 2022. 
 
You asked the Plan to waive the cost share amounts for the operating room services and self-administered 
drugs. You say that you believe these charges should be removed because you were unconscious at the time, 
and these were life saving measures that were provided. 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 $345 
copayment per day for days 1 to 5 for Inpatient hospital care.  
 
The Plan also must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. 
 
You have been asked to pay a $345 copayment per day for days 1 to 5 for the operating room services. This 
item/service 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 
cost share amounts for the operating room services and self-administered drugs provided on May 12, 2022, and 
May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical or vaginal cancer screening; pelvic examination 
provided on April 20, 2022. 
 
You asked the Plan to pay for the cervical or vaginal cancer screening; pelvic examination. You say that you 
did not have a pap test done during this visit. You say that you only had a pelvic exam and you should not be 
charged $100 for the pelvic exam because your doctor is in-network and this is a preventive benefit. The Plan 
denied your request. The Plan says the Plan and Medicare cover a cervical and vaginal cancer screening once every 24 months. You previously received a cervical and vaginal cancer screening on April 12, 2021, which 
was processed and paid under claim number 21B153454900. 
 
The Plan contract covers a cervical and vaginal cancer screening benefit. The Plan covers pap tests and pelvic 
exams a every 24 months. 
 
We looked at the file and the Plans rules. The file shows that you have exceeded the benefit limit of a pelvic 
exam every 24 months. Therefore, we decided that the Plan does not have to pay for a cervical or vaginal 
cancer screening; pelvic examination provided on April 20, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Aranesp. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided and 
the Medicare-approved major drug compendia there is no indication that the plan's required drugs would likely 
be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on April 15, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes. 
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no 
separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services rendered on April 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report 
rendered on March 30, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 27, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report 
rendered on March 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Octreotide. 
 
You asked the Plan to pre-approve Octreotide. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Octreotide.  
 
Benefits for Octreotide may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplicate mammography services (procedure code 77067) 
provided to the enrollee on November 4, 2021. 
 
You asked the Plan to pay for the services. You say that there were multiple exams on this date of service. The 
Plan denied your request. The Plan says the claim was already processed. 
 
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 77067 is "Screening mammography, bilateral (2-view 
study of each breast), including computer-aided detection (CAD) when performed." 
 
We find that the duplicate CPT code 77067 is not supported in the medical record. Specifically, there are two 
imaging reports in the records. However, there are duplicates of one another and do not provide any evidence 
that separate mammography services were rendered. 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 
duplicate mammography services (procedure code 77067) provided to the enrollee on November 4, 2021.
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 is too weak to undergo treatment. The 
Plan denied your request. The Plan says the enrollee dos does not have complex care needs that require a 
coordinated team approach. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for syncope, dehydration, and adult failure to thrive. 
Medical problems are stable.  The complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for aortography (procedure code 75625) provided to the enrollee 
on December 23, 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 records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 75625 is "Aortography, abdominal, by serialography, 
radiological supervision and interpretation." 
 
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 there is insufficient description of 
the abdominal aortogram to justify reimbursement. The procedure would be roadmapping portion of the 
already paid CPT 37225. It is thus not eligible for separate reimbursement per the guidelines. 
 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 aortography (procedure code 75625) provided to the enrollee on December 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 20, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
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 laboratory services related to end-stage renal disease (ESRD) provided on April 
20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing or skilled therapy needs. Daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs can, as a practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 08, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you should not be responsible to 
pay this. 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 $45 
copayment for a specialist visit. 
 
You have been asked to pay a $45 copayment for a specialist visit. This item/service falls within the a specialist 
visit 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 specialist visit provided on 
July 08, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83787 billed for date of service March 9, 
2022. 
 
You asked the Plan to pay for procedure code 83787. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83787 is bundled into payment for code G0481.  
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 83787 
is a column II code to column I code G0481. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 83787 billed for date of service March 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Part B injectable provided on June 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Part B injectable. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 Part B injectable provided on June 3, 2022, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic on January 04, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic. You say that you want to appeal the 
amount being charged. 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 $25 
copayment for Medicare-covered non-radiological diagnostic services. Covered services include but are not 
limited to other outpatient diagnostic tests  non-radiological diagnostic services.  
 
You have been asked to pay a $25 copayment for outpatient diagnostic. This item/service 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 diagnostic on January 04, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 77067-26 billed for date of service September 13, 2021. 
 
You asked the Plan to pay for code 77067-26. You say that the patient had multiple exams on this date of 
service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 15, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 77067-26 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 77067-26 billed for date of service September 13, 2021.