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

 
We decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750) provided on March 31, 
2022. 
 
You asked the Plan to pay for the immunization. You say that your spouse was advised by a plan representative 
that the shingles vaccine was covered as preventive. You say that you received a bill for $227. You say that 
you would be happy to pay the $40 copayment. You also say that the rest should be covered. The Plan denied 
your request. The Plan says the shingles vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization. 
Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750) provided on 
March 31, 2022.  
 
 
 
 
 
 
  
Benefits for the immunization may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on July 26, 
2022, to July 27, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you shouldnt have to pay for 
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 $150 
copayment for Outpatient surgery in a hospital outpatient facility. 
 
You have been asked to pay a $150 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery in a hospital outpatient facility 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. You have been asked to pay $150 copayment per outpatient 
surgical procedure. You have been asked to pay a total of $257.68 which is less than the standard $150 
copayment per procedure. Therefore, we decided that the Plan does not have to waive the copayment for 
outpatient surgery provided on July 26, 2022, to July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat lumbar sacral transforaminal epidural steroid 
injection (ESI) (64493). 
 
You asked the Plan to pre-approve the ESI. You say that you want to appeal this denial. The Plan denied your 
request. The Plan says a repeat injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) is medically 
necessary when the first injection directly and significantly provided at least 50% pain relief for at least three 
months. 
 
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 ESI. Our reviewer says that the 
requested ESI is not medically necessary. Our physician reviewer found the provided documentation does not 
support that the enrollee experienced 50% pain relief for three months. Therefore, the reviewer found that the 
requested ESI is not medically 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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a repeat lumbar sacral transforaminal epidural steroid injection (ESI) (64493).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 25, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service August 25, 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 LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says inpatient rehabilitation facility (IRF) or 
even a skilled nursing facility (SNF). 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you feel that the services received by the 
EMS team should be covered by the Plan. The Plan denied your request. The Plan says these services are not a 
covered benefit. 
 
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 9, 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 the ambulance services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 1, 2022, to May 
20, 2022. 
 
You asked the Plan to pay for the home health services. You say that the NOA was submitted. The Plan denied 
your request. The Plan says the claim has not been billed with the correct admission date. 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We looked at the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from May 1, 2022, to May 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says a SNF admission is not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and copayment for Medicare Part B 
Prescription Drugs and outpatient diagnostic tests provided on April 18, 2022 
 You asked the Plan to waive the coinsurance and copayment for Medicare Part B Prescription Drugs and 
outpatient diagnostic tests. You say that you disagree with the cost share. 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% 
coinsurance for Medicare Part B Prescription Drugs $20 copayment for outpatient diagnostic tests/Medicare-
covered non radiological diagnostic services a $110 copayment for outpatient diagnostic tests/Medicare-
covered radiological diagnostic services a 20% coinsurance for outpatient diagnostic tests/Medicare-covered 
medical supply. 
 
You have been asked to pay a 20% coinsurance for Medicare Part B Prescription Drugs and $20 copayment, a 
$110 copayment and a 20% coinsurance for outpatient diagnostic tests. The total allowed amount for the 
prescription drugs is $245.15 ($245.15 x 20% = $49.03). The total allowed amount for the medical supplies is 
$1,040.45 ($1,040.45 x 20% = $208.09). The total amount you are being asked to pay for all services is 
$387.12 ($110 + $20 + $208.09 + 49.03 = $387.12). 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 and 
copayment for Medicare Part B Prescription Drugs and outpatient diagnostic tests provided on April 18, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical records. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure codes 33508 and 33999) 
provided to the enrollee on March 23, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 33508: 
 
Endoscopy, surgical, including video-assisted harvest of vein(s) for coronary artery bypass procedure (List 
separately in addition to code for primary procedure) 
 
 
 CPT 33999: 
 
Unlisted procedure, cardiac surgery 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 33508 has a bundled 
relationship with CPT 33533 which was billed on this date of service. CPT 33508 was not billed with an 
appropriate modifier to bypass this edit. Additionally, CPT 33999 cannot be verified. The medical records 
provided do not include documentation to validate an unlisted procedure, cardiac surgery being performed on 
March 23, 2021. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure codes 33508 and 33999) provided to the enrollee on March 23, 
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 will receive the appropriate level of care 
in the IRF. The Plan denied your request. The Plan says the denial of IRF care is correct. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and does not need rehabilitation physician closer 
supervision 3 times per week. While the enrollee would benefit from physical and occupational therapy, rehabilitation needs can be safely met in a lower intensity setting such as a skilled nursing facility. 
 
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 waive the copayment for CT scan provided on July 1, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you are requesting reduction of a $75 
copayment to a $15 copayment. 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 $75 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $75 copayment for CT scan. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for CT scan provided on July 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 20, 2022, to 
June 24, 2022, 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 these 
services were reported correctly and are supported as billed. The Plan denied your request. The Plan says the 
DRG submitted on this claim is not supported in the medical records provided. 
 
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 urinary tract infection, site not specified (N39.0). 
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 this diagnosis is not supported in the medical record. Our physician 
reviewer found that the medical records do not show the enrollee had any signs and symptoms of urinary tract 
infection. The urine culture was negative, and antibiotics were not administered. The review has determined 
that the documentation did not support urinary tract infection, site not specified (N39.0).  
 
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 June 20, 2022, to June 24, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you have no one at home to help you and you may 
fall and cause unconsciousness. The Plan denied your request. The Plan says admission to a SNF is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing is proven medically necessary. The Plan 
denied your request. The Plan says the claim was billed with an incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. 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 the lab services provided on July 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for MRI provided on June 16, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you are disputing the share cost. 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 $275 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $275 copayment for MRI. This item/service falls within the outpatient diagnostic 
tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for MRI provided on June 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with semaglutide. 
 
You asked the Plan to pre-approve semaglutide. You say that the requested drug is a necessity for your care. 
The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of semaglutide have been met. 
Specifically, no medical records nor physician order have been provided to support the medical necessity of the 
requested drug. Therefore, we decided that the Plan does not have to pre-approve treatment with semaglutide.