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

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on May 18, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you cannot afford 
to pay the charges. The Plan denied your request. The Plan says since there was no transport, ambulance 
charges are not covered. 
 
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 May 18, 2022. 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 ambulance response and treatment, no transport 
(A0998) provided on May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on July 8, 2022. 
 
You asked the Plan to pay for an eye refraction. You say that the service was necessary and should be covered. 
The Plan denied your request. The Plan says the service at issue is not a covered benefit when performed 
during a medical eye examination. 
 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.  
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of an eye refraction have not been met. Specifically, eye refraction is only covered by the Plan when 
it is performed as part of a routine vision examination. This service was performed for medical vision purposes, 
and therefore is not a covered benefit. Therefore, we decided that the Plan does not have to pay for an eye 
refraction (92015) provided on July 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on June 20, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you did not have an ultrasound and 
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 $60 
copayment for an ultrasound.  
 
You have been asked to pay $60 for an ultrasound. The documentation submitted clearly shows that an 
ultrasound was provided on the date of service in question. This item/service falls within the ultrasound 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 ultrasound provided on June 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable, ready for 
discharge, and appropriate for transfer to an LTACH. You say that the enrollee requires prolonged and 
intensive skilled services that are not available at a lower level of care. The Plan denied your request. The Plan 
says the enrollee is receiving appropriate inpatient acute care and is currently unstable for transfer to an 
LTACH. 
 
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 have recently become less stable and requires short-term 
additional acute care service that can safely be administered at the current facility. Transfer to the LTACH 
would not be clinically advantageous at this time and completion of treatment at the current facility is 
recommended. 
 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on November 19, 2021. 
 
You asked the Plan to pay for the services provided. You say that the date of service is compatible with the 
code billed. The Plan denied your request. The Plan says it is not appropriate to report the conditions together. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The records show that diagnosis codes J96.00 and R06.02 were reported. 
Diagnosis code group R06 excludes respiratory failure codes J96. 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 critical care services provided on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on May 12, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. 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 $40 
copayment for laboratory services at a provider's office.  
  
You have been asked to pay $18.36 for laboratory services, which is less than the standard $40 copayment. 
This item/service falls within 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 laboratory services provided on May 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device has not been shown to be safe and effective in long term studies and there is 
a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of 
decompression. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the device is experimental. More research is needed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visits on February 23, 
2022, and March 23, 2022. 
 
You asked the Plan to waive the copayments for the specialist office visits. 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 $20 
copayment for an in-network specialist's office visit.  
 
You have been asked to pay $40 for specialist office visits ($20/visit x 2 visits = $40). This item/service falls 
within the specialist's office 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 copayments for 
the specialist office visits on February 23, 2022, and March 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for a positron emissions tomography 
(PET) scan with concurrently acquired computed tomography (CT) scan (78815) provided on May 16, 2022. 
 
You asked the Plan to pay an additional amount for a PET scan with concurrently acquired CT scan. You say 
that you want the Plan to pay an additional amount for the service. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 50% coinsurance for out-of-network advanced imaging services.  
 
   
The enrollee has been asked to pay a 50% coinsurance for a PET scan with concurrently acquired CT scan. 
This item/service falls within the out-of-network advanced imaging services benefit category. This means that 
the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to pay an additional amount for a positron emissions tomography (PET) scan with concurrently 
acquired computed tomography (CT) scan (78815) provided on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services received were medically necessary. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided by an opted-out Doctor of 
Dental Surgery provided from March 8, 2021, to March 12, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial, and that this 
provider was recommended to you by your dentist. The Plan denied your request. The Plan says your provider 
has opted out of Medicare 
 
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 the dental 
services provided by an opted-out Doctor of Dental Surgery provided from March 8, 2021, to March 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 26, 2021, to 
October 29, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the DRG billed is not supported by 
the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, A419, defined as sepsis, 
unspecified organism. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support the DRG 
billed. Our physician reviewer found the enrollee presented after being found down in a puddle with a 
laceration on the arm indicating a possible fall. Emergency department exam documented vital signs of 
temperature of 94.1F, pulse 81, respiratory rate 17, blood pressure 137 over 84 and pulse oxygen saturation 
(SpO2) 97% on room air. The enrollee was described as in no acute distress, lungs clear to auscultation 
bilaterally, respiratory effort not labored, alert and oriented to place but not person, or time, and muscle wasting 
present. Laboratory test results included a white blood cell count of 23.4K, platelet count 305K, blood urea 
nitrogen 21, creatinine 1.3, total bilirubin 1.5, and lactic acid 1.92. The enrollee's chest x-ray revealed no acute 
abnormalities. The enrollee was diagnosed with elevated troponin secondary to non-ST-elevation myocardial 
infarction (NSTEMI) and admitted for further care. Treatment included IV fluids. While it is acknowledged 
that the records include a physician-documented diagnosis of sepsis, and that Systemic Inflammatory Response 
Syndrome (SIRS) signs were present, the clinical findings in the record do not sufficiently support the 
diagnosis of sepsis based on Sepsis 3 criteria. Therefore, the principal diagnosis billed A41.9, (Sepsis, 
unspecified organism) is not supported by the documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 26, 2021, to October 29, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on June 2, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that calling the 
ambulance was necessary for your condition and you want the Plan to pay for the service. The Plan denied your 
request. The Plan says the ambulance benefit is a transportation benefit. Since you did not receive transport, the 
service is not covered. 
 
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 June 2, 2022. 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 ambulance response and treatment, no transport 
(A0998) provided on June 2, 2022.
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 strength to get back home. The 
Plan denied your request. The Plan says the enrollee will not be able to fully participate in an intensive therapy 
program. 
 
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 for a stroke. She is at a minimal to moderate assist for 
transfers and ambulation a short distance. Dementia limits her capacity to participate in intensive therapy. She 
does not have complex or specialized needs and does not require frequent oversight from a physiatrist. 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81479 provided on April 4, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 code 81479 is not supported in the medical record. Specifically, the documentation shows 
that specimen was collected on March 24, 2022. This means there is no documentation to support the testing on 
the billed date of service. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded 81479 provided on April 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durysta. 
 
You asked the Plan to pre-approve Durysta. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says coverage for Durysta requires that the enrollee has not 
already been treated with Durysta. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pre-approve Durysta. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found that based on the 
medical records provided and the Medicare-approved major drug compendia there is no documentation that the 
Durysta at issue in this case meets all Medicare criteria for medically reasonable and necessary for the patient. 
As stated in the major drug compendia, directions for Durysta state: "Implant intracamerally one time. Do not 
readminister to an eye with a prior bimatoprost intracameral implant." As the enrollee has already received 
Durysta, a second administration is not medically 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 Durysta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durysta.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2025), progressive lenses (V2781), and 
anti-reflective coating (V2750) received on April 22, 2022.  
You asked the Plan to pay for deluxe frames, progressive lenses, and anti-reflective coating. You say that the 
items should be covered, and you want the Plan to reimburse you. The Plan denied your request. The Plan says 
your deductible for out-of-network services had not been met, and the anti-reflective coating is not covered. 
 
Medicare generally does not cover routine vision and eyewear services, except for eyewear provided after a 
cataract surgery. For this eyewear, anti-reflective coating (V2750) is only covered when medical necessity is 
documented. The rules also say that Plans must disclose cost sharing in clear and accurate terms. The contract 
with the Plan states that a $575 deductible applies to Medicare-covered eyewear that was provided out-of-
network. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of anti-reflective coating have not been met. Specifically, the file does not include any documentation 
of medical necessity by the treating provider for the anti-reflective coating. Additionally, the deluxe frames and 
progressive lenses were received from an out-of-network provider and the out-of-network deductible had not 
been met. The Plan correctly applied the deluxe frames and progressive lenses to the out-of-network 
deductible. Therefore, we decided that the Plan does not have to pay for deluxe frames (V2025), progressive 
lenses (V2781), and anti-reflective coating (V2750) received on April 22, 2022.