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

 
We decided that the Plan does not have to pay for outpatient surgery provided on July 05, 2022. 
 
You asked the Plan to pay for outpatient surgery. You say that you are requesting a reconsideration of the 
denied claim because the CPT code 66821 does not require an authorization. The Plan denied your request. The 
Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for outpatient surgery 
provided on July 05, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for 
date of service February 4, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says this code is 
included in the facility payment and is not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service February 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation care provided from 
June 17, 2022, to June 21, 2022. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation care. You say that you do not 
understand why you were charged as an inpatient while in rehab. 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 $340 
copayment per day for days 1-6 for inpatient hospital care.  
 
 
  The file shows that your inpatient rehabilitation stay lasted 4 days from June 17, 2022, to June 21, 2022. You 
have been asked to pay a $340 copayment per day for the 4 days of inpatient rehabilitation care. The total for 
your stay would be $1,360. However, the total amount charged is only $1,354 due to meeting your maximum 
out-of-pocket (MOOP) expenses for the year. This item/service falls within the inpatient hospital 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 inpatient rehabilitation care provided from June 
17, 2022, to June 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided from January 25, 
2022, to January 27, 2022. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously 
paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 31, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for the physical therapy services have not been met. 
Therefore, we decided that the Plan does not have to pay for the physical therapy services provided from 
January 25, 2022, to January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown lengthening services (D4249) provided on May 4, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for crown 
lengthening services (D4249) provided on May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 11, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of aorta, inferior vena cava, iliac vasculature, or 
bypass grafts; complete study provided to the enrollee on July 11, 2022. 
 
You asked the Plan to pay for the scan. You say that the enrollee's medical condition proved medical necessity 
as indicated in the report. The Plan denied your request. The Plan says the diagnosis is inconsistent with the 
procedure. 
 
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 pay for the scan. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is documentation in two areas including the diagnosis code and in the history narrative that this 
was a screening study. However, this study was billed as a complete study, a code typically used for a non-
screening complete exam. No other supporting materials are provided that would help identify a billable 
indication for the study. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pay for duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study provided 
to the enrollee on July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204, 99213, 11042, 99212), provided on 
January 28, 2022, to March 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says prior authorization must be obtained for non-emergent services received 
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 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 office visit (99204, 99213, 11042, 99212), 
provided on January 28, 2022, to March 11, 2022, 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 the psychotherapy services provided on July 14, 2022 to July 
19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy services. You say that you were not aware that a prior 
authorization was required. The Plan denied your request. The Plan says no authorization is on file for these 
services. 
 
 
 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 psychotherapy services provided on July 14, 
2022 to July 19, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider 
form March 16, 2022, to March 22, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you should be reimbursed for the hearing aid. The 
Plan denied your request. The Plan says items are to be supplied by network providers. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when supplied by a network provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the provider was out-of-network. Therefore, we 
decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider form 
March 16, 2022, to March 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this procedure fills a treatment gap for patients that 
do not receive adequate relief from traditional conservative methods and do not have instability to indicate that 
fusion is appropriate. The Plan denied your request. The Plan says this procedure is not medically 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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are multiple possible pathologic sources of significant pain. The non-radiating midline 
back pain along with the intact neurological exam are non-specific to any pathologic entities. Overall, 
documentation is lacking regarding reasonable detailed findings supportive of the vertebral bodies as being the 
overwhelming primary generators of the enrollee's chronic pain. There is no compelling rationale or 
extenuating circumstance noted to support the necessity of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, nail debridement, and trimming of skin lesion 
provided on July 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you were informed the office checked your 
eligibility. You say that they did not inform you that you needed an authorization. You also say that you should 
not be responsible for this bill. The Plan denied your request. The Plan says prior authorization was not 
obtained. 
 
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 did not pre-approve the service at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the office visit, nail debridement, and trimming of skin lesion provided on 
July 12, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided on 
May 30, 2022, to July 15, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. 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 20% 
coinsurance for home health agency care. The allowed amounts of these durable medical equipment total $566, 
resulting in a total coinsurance amount of $113.20. 
 
You have been asked to pay 20% coinsurance for durable medical equipment. This item/service falls within the 
home health agency 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 coinsurance for durable 
medical equipment provided on May 30, 2022, to July 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says this 
treatment is not being used as a last resort. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are only covered under certain 
medical indications.  
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has post-laminectomy syndrome. The enrollee is still being evaluated for 
further surgery. Therefore, the request is not the last or late resort for pain management in this enrollees case.  
Therefore, the request is considered 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic colonoscopy, provided on January 7, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic colonoscopy. You say that the service was medically necessary. 
The Plan denied your request. The Plan says prior authorization must be obtained for services obtained 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 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 diagnostic colonoscopy, provided on January 
7, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided December 28, 
2021, to December 30, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient admission was medically 
necessary. The Plan denied your request. The Plan says the required services could have been provided in a less 
intense setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found based on the low severity and complexity and expected quick improvement with 
initial treatment and monitoring, it was not expected that the enrollee's hospital treatment would have likely 
crossed 2 midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided December 28, 2021, to December 30, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's symptoms interfere with 
activities of daily living. The Plan denied your request. The Plan says the enrollee does not have significant 
edema. 
 The Plan follows Medicare rules. Medicare rules say that the treatment of varicose veins is only covered under 
certain medical indications.  
 
The file shows that endovenous ablation therapy and stab phlebectomy services were requested. 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 requested services. Our physician reviewer found 
that coverage criteria requires that the enrollee fail a 6-week trial of conservative therapy. The enrollee has not 
been seen for her varicose veins in years. It is documented that she is not using compression stockings. There is 
no evidence in the medical record that a concerted effort at conservative therapy was attempted. It should also 
be noted that the Plan does not cover simultaneous stab phlebectomy with treatment of truncal reflux. A 
rationale for this is that many may experience satisfactory resolution of the symptoms with the ablative therapy 
alone. Therefore, the requested services are 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovenous services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service July 16, 
2022. 
 
You asked the Plan to pay for procedure code 86077. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service July 16, 2022.