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

 
We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on October 18, 
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 procedures were not appended with the appropriate modifier. 
 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 76705 
is a column II code to column I code 93976. 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 ultrasound services provided to the enrollee on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2308, V2750) purchased on 
October 21, 2021. 
 
You asked the Plan to pay for the eyeglasses. You say that you confirmed with the Plan that you would be 
purchasing these eyeglasses within your benefit's allowed time frame, because you needed these services 
covered. The Plan denied your request. The Plan says these services have been covered and paid up to your 
$300 benefit allowance limit. You are responsible for the charges that exceeded this limit. 
 
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 up to $300 every calendar year. You are responsible for the difference 
in cost if the cost of the eyewear exceeds this allowance. 
 
We looked at the file and the Plan's rules. Documentation shows that the total cost of the eyeglasses purchased 
on October 21, 2021, was $564. The record shows that the Plan has paid the full $300 allowance, and you are 
being asked to pay the remaining $264. Expenses for eyewear in excess of the $300 annual allowance offered 
by the Plan are not covered. This means you have been asked to pay the correct amount based on your contract 
with the Plan. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2308, 
V2750) purchased on October 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on October 8, 2021. 
 
You asked the Plan to pay for the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 pay for self-administered drugs received 
on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Botulinum Toxin Type A (Botox)
injection you received on November 1, 2021.
You asked the Plan to waive the coinsurance for the Botox injection. You say that you were told this was
covered and never advised that you would have to pay 20% coinsurance. The Plan denied your request. The
Plan says you were charged this coinsurance 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 20%
coinsurance for Medicare Part B drugs.
You have been asked to pay 20% coinsurance for the Botox injection. The Botox injection falls within the
Medicare Part B drugs 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 the
Botulinum Toxin Type A (Botox) injection you received on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care discharge day management (99217)
provided September 28, 2021.
You asked the Plan to pay for the hospital services. You say that please review the attached information and
reprocess this claim. The Plan denied your request. The Plan says the information submitted does not support
this many/frequency of services.
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 99217 is observation care discharge day management.
We find that CPT code 99217 is not supported in the medical record. Specifically, the enrollee's claims history
does not show a qualifying initial (99218-9220) or subsequent observation care (99224-99226) codes. Based on
this information, we decided that Medicare rules for coverage of the hospital services have not been met.
Therefore, we decided that the Plan does not have to pay for observation care discharge day management
(99217) provided September 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN)
(G0299).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the home health nursing visits are not medically necessary for your condition.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found you do not appear
to be homebound. The documentation does not show any home health skilled nursing needs, such as IVs,
complex wound care, new ostomy care/teaching, etc. As such, the requested home health skilled nursing
services are not medically necessary or reasonable.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve direct skilled nursing services of a registered nurse (RN) (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on October 7,
2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The 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 medical services provided to the enrollee on
October 7, 2021.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had 
stable vital signs and was treated for aspiration pneumonia. The enrollee was at a supervision to contact guard / 
minimal assist level with functional mobility including gait to 60 feet x 3. The enrollee does not require skilled 
nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria 
for an inpatient basis in a skilled nursing facility setting. 
 
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: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pre-approve psychotherapy services to be rendered by the out-of-network
(OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the
Plan's denial to obtain care from a Mandarin speaking therapist. The Plan denied your request. The Plan says
that there are in-network providers available to render the requested services with the aid of an interpreter.
Medicare rules say that MAOs are required to establish and maintain provider networks that ensure that all
services, both clinical and non-clinical, are provided in a culturally competent manner and are accessible to all
enrollees, including those with limited English proficiency, limited reading skills, hearing incapacity, or those
with diverse cultural and ethnic backgrounds.
The Plan has not shown that they have a mental health provider able to provide culturally competent care. We
find that an interpreter is not an adequate replacement for a Mandarin-speaking therapist given time constraints
and the sensitive nature of mental health services. Therefore, we decided that the Plan has to pre-approve
psychotherapy services to be rendered by the out-of-network (OON) provider.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 23, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says no separate
payment is made.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, the CPT Code Manual definition of code 99000 is handling and/or conveyance of specimen for
transfer from the office to a laboratory. We find that CPT code 99000 is a bundled code. When these services
are covered, payment for them is subsumed by the payment for the services to which they are incident.
The CPT Code Manual definition of code G0483 is definitive drug testing of 22 or more drug classes. We find
that CPT code G0483 is not supported by the medical records. The medical records show that the enrollee's
sample was sent for further analysis despite the screening only appearing positive for the enrollee's prescribed
medications. The records do not show that the testing was ordered based on suspicious behaviors, selfescalation of dose, symptoms of illegal drug use, or other clinician documented change in behavioral pattern.
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we
decided that the Plan does not have to pay for the drug testing services provided on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the copayment for the emergency room services you received
on January 16, 2021, under your Pick Your Perks supplemental benefit.
You asked the Plan to pay for the copayment. You say that you feel as though you are being ripped off because
the Plan won't pay for this. The Plan denied your request. The Plan says copayments are not covered under this
benefit.
The Plan must follow Medicare rules. Medicare rules say that Plans may offer additional coverage as a
supplemental benefit. In cases where a Plan offers a supplemental benefit, the Plan's contract rules apply. In
this case, your Plan contract says that under its "Pick Your Perks" supplemental benefit, the following expenses
are eligible for coverage: routine dental, vision hardware, non-emergency transportation, home-delivered
meals, acupuncture, massage, over-the-counter items, and nutritional/dietary counseling. This benefit does not
list copayments as covered under this benefit.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says that you 
have no acute symptoms or needs requiring 24-hour inpatient care. 
 
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. 
 
We looked at the file and the rules. We requested medical records in order for our physician to determine if the 
Plan was correct in denying the request. However, the case file does not show that the Plan made a diligent 
effort to obtain records after our request was submitted. Additionally, the psychiatry provider and the hospital 
in this case are both contract providers. Contract providers are considered agents of the plan, so it would be up 
to the plan to provide these records. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan 
has to pre-approve continued inpatient psychiatric services.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided to the enrollee on August 
18, 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 diagnosis codes should not be reported together. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 
 
 
 
 
 
 
 
 We find that CPT codes 99291 and 93010 is not supported in the medical record. Specifically, the two 
diagnosis codes billed on the claim - R09.02 and J80 - are not allowed to be reported together. 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 emergency room services provided to the enrollee on August 18, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not have skilled nursing or therapy needs that need to 
be provided on a daily basis as an inpatient only status. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you received oral medications, had stable vital 
signs and was treated for pain. You were at a supervision/stand by assist to contact guard assist level with 
functional mobility including gait to 125 feet. You do not require skilled nursing or therapy services on a daily 
basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
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 injection (ESI) services. 
 
You asked the Plan to pre-approve ESI services. You say that the clinical documentation provided supports the 
need for the injection services. The Plan denied your request. The Plan says the clinical information does not 
demonstrate that the requested procedure is indicated at this time. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESI services are only covered for certain 
medical indications.  
 
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 ESI services. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee underwent a L4-L5 ESI on 
January 3, 2022, which provided 95% pain relief. Three months has not passed since this last injection. There is 
no evidence that the enrollee failed to respond well to the initial ESI and that there is a need for a repeat ESI 
after only 14 days. 
 
 
 
 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ESI services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve epidural steroid injection (ESI) services.
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 requested admission to a SNF is medically
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet
criteria.
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 daily
skilled services are not necessary. Our physician reviewer found you received oral medications, had stable vital
signs and had routine foley catheter care. You do not require skilled nursing or therapy services on a daily
basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled
nursing facility setting.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the insulin injection provided in an outpatient setting from
February 26, 2021, to March 1, 2021.
You asked the Plan to pay for the self-administered drug. You say that this should be covered. The Plan denied
your request. The Plan says the insulin injection provided in an outpatient setting is considered selfadministered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug
plan. The Plan also says the insulin injection is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered 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 pay for the insulin injection provided in
an outpatient setting from February 26, 2021, to March 1, 2021.
Benefits for the self-administered drug may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.