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

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
October 22, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you have yearly 
colonoscopy's due to doctor's recommendations and Lynch guidelines. 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 $300 
copayment for in-network outpatient surgery at an ambulatory surgical center.  
 
Medical records show that polyps were removed during your colonoscopy. Therefore, the colonoscopy is 
considered diagnostic, and the outpatient surgery copayment applies. You have been asked to pay a $300 
copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 diagnostic colonoscopy provided on October 
22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the extracapsular cataract removal with 
insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and 
aspiration or phacoemulsification)(66984) provided October 21, 2021, and November 11, 2021. 
 
You asked the Plan to waive the copayment for the cataract removal with insertion of intraocular lens 
prosthesis. You say that you would like this service covered. The Plan denied your request. The Plan says the 
copayments have been applied 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 $225 
copayment for services provided in an outpatient hospital or ambulatory surgical center. 
 You have been asked to pay a $225 copayment for the cataract removal with insertion of intraocular lens 
prosthesis. The cataract removal falls within the Outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage 
procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification)(66984) 
provided October 21, 2021, and November 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a co-insurance exception for a Lifestyle Libre 
continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a co-insurance exception for a CGM. You say that the exception is needed. 
The Plan denied your request. The Plan says the item does not qualify for co-insurance exceptions. 
 
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping 
Part D drugs into different cost sharing levels within a Part D sponsor's formulary.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a co-insurance exception for a CGM have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a co-insurance exception for a Lifestyle Libre continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the single level fusion (spinal surgery) (CPT code(s): 
22614, 22612, 20930, 22842). 
 
You asked the Plan to pre-approve the spinal surgery. You say that the services are necessary. The Plan denied 
your request. The Plan says the services are not 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 spinal surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documented spinal instability, fracture or lesion. Fusion not needed for 
lumbar DDD. 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 spinal surgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the single level fusion (spinal surgery) (CPT code(s): 22614, 22612, 
20930, 22842).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient mental health care provided on 
November 1, 2021, and November 18, 2021. 
 
You asked the Plan to waive the copayments for outpatient mental health care. You say that you disagree with 
the charges and would not have gone in person if you had known. The Plan denied your request. The Plan says 
the claims were processed correctly and you are being charged the correct 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 outpatient mental health care provided in an outpatient hospital facility.  
 
You received outpatient mental health care on November 1, 2021, and November 18, 2021, at an outpatient hospital facility. Therefore, you are responsible to pay a $100 copayment per each visit. The total amount you 
owe is: $100 (copayment) x 2 (visits) = $200.  
 
You have been asked to pay the total copayment amount of $200 for outpatient mental health care. Outpatient 
mental health care falls within the outpatient mental health 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 copayments for outpatient mental health care provided on November 1, 2021, and November 18, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine venipuncture and laboratory services  provided on 
October 22, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for routine venipuncture and laboratory services. You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says this provider is not a network provider 
with the Plan, and they have also determined that these services are not urgent or emergent, nor were they 
approved in advance. The Plan also says the referring provider is also non-participating with the Plan. 
 
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 routine venipuncture and laboratory services  
provided on October 22, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract surgery and eyeglasses provided on June 22, 
2021 to July 7, 2021 by an out-of-network (OON) provider. 
 
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 were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the cataract surgery and eyeglasses provided on 
June 22, 2021 to July 7, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for individual psychotherapy services (90837) provided on 
October 18, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that you were unaware that the provider was 
out of network. You have seen this provider in the past and they had been in network at that time. The Plan 
denied your request. The Plan says enrollees must receive their medical services from an in-network provider 
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers 
require prior authorization before services being rendered. 
 
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 individual psychotherapy services (90837) 
provided on October 18, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (3078F, 99397, 99214, 3074F) provided on 
July 28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the rendering provider is a non-participating provider and there is no 
referring provided involved in these services. The Plan also says they did not authorize any services for this 
provider. 
 
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 an office visit (3078F, 99397, 99214, 3074F) 
provided on July 28, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (37223, 75716, 37252, 37253) provided 
August 12, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed 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. 
 
 
 
 
 
 We find that CPT codes 37223, 75716, 37252, & 37253 are not supported in the medical record. Specifically, 
CPT 71756 would be included in the approved CPT 37221, which would require radiological supervision when 
performed. The operative report does not support that procedures 37223, 37252, & 37253 were performed. 
Based on this information, we decided that Medicare rules for coverage of the surgical services have not been 
met. Therefore, we decided that the Plan does not have to pay for surgical services (37223, 75716, 37252, 
37253) provided August 12, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a physician telehealth visit (99214) on September 1, 2021. 
 
You asked the Plan to pay for a physician telehealth visit. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that PPO plans must cover all Medicare-covered 
services out-of-network but may apply higher cost sharing. Medicare has expanded telehealth coverage to 
allow all providers who may bill Medicare for professional services to be paid for telehealth services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a physician office visit have not been met. Specifically, the Plan is a PPO and cannot deny 
coverage of certain out-of-network services, such as telehealth. The PPO plan is also not allowed to impose 
prior authorization requirements on covered out-of-network care. As such, we find that the Plan has not 
provided any valid denial rationale to support non-payment of this claim. Therefore, we decided that the Plan 
has to pay for a physician telehealth visit (99214) on September 1, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 11 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. You say that the enrollee would benefit from 
ongoing PT services. The Plan denied your request. The Plan says the enrollee's needs have been met with the 
PT that has been previously provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition.  Our physician reviewer found the enrollee underwent shoulder surgery on 6/24/21 and began receiving 
physical therapy on 6/29/21 and has continued until mid-January of 2022. The patient has had prior therapy and 
the documentation does not reveal that the patient requires the unique skills of a professional therapist   to 
safely and effectively provide treatment, or that the services can be safely and effectively performed only by a 
therapist, or under the supervision of a therapist. The patient has had instruction in a HEP. The requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current 
condition or to prevent or slow further deterioration. 
 
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 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 11 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of spinal neurostimulator pulse 
generator or receiver, direct or inductive coupling (CPT code 63685) and percutaneous implantation of 
neurostimulator electrode array, epidural (CPT code 63650). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because the enrollee's records show that they 
only received little improvement, in the enrollee's back pain from the SCS trial. The Plan states the submitted 
records do not show that this device would be used as a last or late resort to try to manage their back pain. 
 
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 physician reviewer 
found the actual psychological evaluation is not included in the submitted documents. Therefore, at this point, 
absent the actual evaluation, the request is not medically reasonable and necessary. 
 
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 insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or 
inductive coupling (CPT code 63685) and percutaneous implantation of neurostimulator electrode array, 
epidural (CPT code 63650).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on August 4, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you did not call the ambulance. You also 
say that you were not transported. The Plan denied your request. The Plan says since there was no transport 
provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 4, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided on August 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be somewhat unstable and will require additional acute care 
services that can safely be administered at the current facility until more stable. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to 
LTACH will be considered not medically necessary as the enrollee is still unstable and as it would not be 
clinically advantageous. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.