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

 
We decided that the Plan does not have to pay for anesthesia services (procedures code 77001 and 99153) 
provided to the enrollee on September 7, 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 services were not reported properly. 
 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 77001 
is a column II code to column I code 36902. This claim has not been billed with an appropriate modifier to 
bypass the edit. Additionally, CPT 99153 cannot be paid, as it has a Professional Component/Technical 
Component indicator of 3. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for anesthesia services (procedures code 77001 and 
99153) provided to the enrollee on September 7, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for computed tomography (CT) scan of the cervical spine, head, and brain 
provided to the enrollee on May 26, 2021. 
 
You asked the Plan to pay for the scan. You say that this is medically necessary. The Plan denied your request. 
The Plan says that there must be preceding documented X-rays, and focal neurologic findings of unilateral 
dermatome distribution of neurologic deficits. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the scan. Our reviewer says that the 
requested scans are medically reasonable and necessary. Our physician reviewer found in a case where there is 
an assault with a heavy metal weapon in the vicinity of the cervical spine CT exam without a focal neurological 
deficit is reasonable due to the nature of the attack.  Likewise, CT of the brain was reasonable as the enrollee 
then fell striking the back of his head. 
 
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 scan have been met. Therefore, we decided that the Plan has to pay for 
computed tomography (CT) scan of the cervical spine, head, and brain provided to the enrollee on May 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 laser eye surgery to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the laser eye surgery. You say that the service is medically necessary. The Plan denied your request. The Plan says the provider is out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve laser eye surgery to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on October 1, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that the services should be covered in 
full as they could have been performed on the same day, The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services provided. 
 
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 Vision care.  
 
 
  You have been asked to pay a $29.67 copayment for an eye exam, which is less than the standard $45 
copayment. The eye exam falls within the Vision 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 an eye exam provided on October 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy (97110, 97140, G0283) provided on March 13, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for physical therapy. You say that your office, the individual provider, as well as the referring provider are all participating providers with Medicare. You also say that the enrollee was treated in your office and was directed by a participating provider. The Plan denied your request. The Plan says the rendering provider is a non-participating provider and the referring provider involved in these services is also a non-participator with the Plan. The Plan also says they did not authorize any services for either the rendering or referring 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 physical therapy (97110, 97140, G0283) provided on March 13, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80323, 80324, 80332, 80335, 80338, 80342,
80345, 80346, 80348, 80349, 80354, 80355, 80356, 80357, 80358, 80359, 80360, 80363, 80364, 80365, 80366,
80368, 80369, 80372, 80373, 80375) provided April 22, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the codes billed are not valid for Medicare payment.
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 80323, 80324, 80332, 80335, 80338, 80342, 80345, 80346, 80348, 80349, 80354,
80355, 80356, 80357, 80358, 80359, 80360, 80363, 80364, 80365, 80366, 80368, 80369, 80372, 80373, &
80375 are not supported in the medical record. Specifically, the codes billed are not included in the Clinical
Diagnostic Laboratory Fee Schedule. Based on this information, we decided that Medicare rules for coverage
of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services
(80323, 80324, 80332, 80335, 80338, 80342, 80345, 80346, 80348, 80349, 80354, 80355, 80356, 80357,
80358, 80359, 80360, 80363, 80364, 80365, 80366, 80368, 80369, 80372, 80373, 80375) provided April 22,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement (11721) rendered by the out-of-network 
(OON) provider on October 21, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the nail debridement (11721) rendered by the out-of-network (OON) provider on 
October 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Myocardial perfusion imaging, 
tomographic (SPECT) test provided on December 1, 2021. 
 
You asked the Plan to waive the coinsurance for the Myocardial perfusion imaging, tomographic (SPECT) test. 
You say that the services should be covered. The Plan denied your request. The Plan says the coinsurance 
applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 You have been asked to pay a 20% coinsurance for the Myocardial perfusion imaging, tomographic (SPECT) 
test (allowed is $535.05 x 20% = $107.01). Myocardial perfusion imaging, tomographic (SPECT) tests fall 
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 coinsurance for a Myocardial perfusion imaging, tomographic (SPECT) test 
provided on December 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 9, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on October 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower extremity prosthesis to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the lower extremity prosthesis. You say that the enrollee feels comfortable 
and confident with the provider at this location.  You say the enrollee refuses to go elsewhere. The Plan denied 
your request. The Plan says the provider is out-of-network. 
 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the lower extremity prosthesis to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided by an out-of-network psychologist from 
February 1, 2021, to March 24, 2021. 
 
You asked the Plan to pay for the psychologist services. You say that you have seen this provider since 2018 
and there has been no issues so far with claims. The Plan denied your request. The Plan says the provider you 
saw has opted out of Medicare, so no payment may be made for these services. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for services 
provided by an out-of-network psychologist from February 1, 2021, to March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on July 28, 2021.
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan denied your request. The Plan says this provider is not a Medicare eligible provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program. The services at issue in this appeal were by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for physician services provided on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cervical or vaginal screening cytopathology (G0145) 
pathology and laboratory services (87624) provided December 9, 2021. 
 You asked the Plan to pay for the diagnostic services. You say that the facility should have been paid the full 
amount because patients have no control over the tests. You had abnormal cells and that is why the doctor 
ordered the other tests. The Plan denied your request. The Plan says this service exceeds the maximum benefit 
allowed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. The health Plan has a benefit that exceeds Medicare 
coverage. For that reason, the Plan's rules apply in this case.  
 
The health Plan contract says that Pap tests and pelvic exams are covered once every 24 months. The records 
show that the enrollee has a screening on 10/22/2020 which is less than 24 months to the visit at issue in this 
case. Therefore, we decided that the Plan does not have to pay for cervical or vaginal screening cytopathology 
(G0145) pathology and laboratory services (87624) provided December 9, 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 needs partial assistance with activities of 
daily living. The Plan denied your request. The Plan says the enrollee seems to be unwilling to fully participate. 
 
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 care hospital with nausea, vomiting, and weakness. The 
documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
documentation does not support that she requires at least 3 hours a day. The documentation supports that the 
services may 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 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 imaging services provided to the enrollee on September 10, 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 provider did not bill as required by Medicare coding regulations.
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 77001
is a column II code to column I code 49446. This claim has not been billed with an appropriate modifier to bypass the edit.
Additionally, CPT 99153 has a professional component/technical component indicator of 3, so it was not
reported correctly in this case. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on 
September 7, 2021. 
 
You asked the Plan to reimburse you an additional amount for the eyeglasses. You say that you should be 
eligible to receive up to $150 in benefits. The Plan denied your request.  The Plan says although the vision benefit allows the member to receive a $150 allowance toward their purchase 
of frames, the Plan will not reimburse the member for more than what was paid for the covered benefits or non-
covered services. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine 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 $150 allowance for covered eyewear.  
 
We looked at the file and the Plan's rules. The file shows that the Plan has paid the total allowed amount of 
$73.99, which is less than the maximum eyewear allowance of $150. The Plan benefit does not provide 
coverage for anti-reflective coating and tinting. Therefore, we decided that the Plan does not have to reimburse 
you an additional amount for eyeglasses provided on September 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve family therapy to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the family therapy. You say that you need a family therapist which the insurance does not offer. You would appreciate being allowed to see the family therapist to help your family. The Plan denied your request. The Plan says the provider is out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve family therapy to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services (92012) provided on July 19, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee has not out-of-network benefits and the 
servicing provider is not a participating provider with the Plan. The Plan also says that they determined that the 
services the enrollee received were not urgent or emergent. 
 
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 ophthalmological services (92012) provided on 
July 19, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy assistant (PTA) services provided on 
September 22, 2021. 
 
You asked the Plan to pay for the PTA services. You say that this should be covered due to medical necessity. 
The Plan denied your request. The Plan says there is a more appropriate code for the services at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that only a therapist can bill for the services of a 
PTA. NPPs are not allowed to be paid for this as they do not meet the definition of a therapist.  
 
The PTA services were billed by an NPP, which is not allowed per Medicare guidelines. Therefore, we decided 
that the Plan does not have to pay for the physical therapy assistant (PTA) services provided on September 22, 
2021.