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

 
We decided that the Plan does not have to waive the copayment for electrocardiogram provided on June 16, 
2022. 
 
You asked the Plan to waive the copayment for electrocardiogram. 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 $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $138.93 which is less than the $150 copayment for electrocardiogram. 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 electrocardiogram provided on June 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 April 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance (eg, proton) imaging, any joint of 
lower extremity; without contrast material (73721). 
 
You asked the Plan to pre-approve an MRI of the right ankle, without contrast. You say that an MRI is 
medically necessary. The Plan denied your request. The Plan says you have not completed six weeks of 
provider directed treatment within the last three months and there was no contact with your provider after 
completing treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 pre-approve an MRI of the right ankle, without 
contrast. Our reviewer says that an MRI is not medically necessary. Our physician reviewer found that there is 
no recent physical therapy for leg pain and dysfunction. More conservative measures are 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 an MRI of the right ankle, without contrast have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a magnetic resonance (eg, proton) imaging, any joint of 
lower extremity; without contrast material (73721).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93312 billed for date of service December 
29, 2021. 
 You asked the Plan to pay for procedure code 93312. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 93312 is bundled into payment for code 00567. 
 
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 93312 
is a column II code to column I code 00567. 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 93312 billed for date of service December 29, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 16, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the services were billed, rendered, and referred by non-participating 
providers. The Plan also says that these services were not approved in advance. 
 
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 laboratory services provided on July 16, 2022, by 
an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 3, 2022. 
 You asked the Plan to pay for the ambulance services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance services must be billed with the 
appropriate modifiers to describe the origin and destination of the ambulance trip.  
 
We looked at the file and Medicare rules. Review of the file shows that the ambulance services were billed 
with modifier RW. W is not listed as a modifier to be billed for ambulance service claims. This means this 
modifier is considered an invalid modifier for the ambulance service and therefore, not payable as billed. Based 
on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiogram (EKG) reporting (93042) provided on 
March 19, 2022. 
 
You asked the Plan to pay for EKG reporting 93042. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says code 93042 has a procedure-to-procedure (PTP) edit of 0 with 
code 99291 so is not separately payable. 
 
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 93042 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for electrocardiogram (EKG) reporting (93042) provided on March 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the cardiac rehabilitation services 
provided from February 7, 2022, to June 10, 2022. 
 
You asked the Plan to waive the copayments for the cardiac rehabilitation services. You say that you would 
like the all the sessions to be considered as 1 visit and charged as only 1 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 a $40 
copayment for Medicare-covered cardiac rehabilitation services. From February 7, 2022, to June 10, 2022, 
there was a total of 24 rehabilitation visits. The total copayment amount for the 24 rehabilitation visits was 
$960 ($40 copayment per visit x 24 visits). 
 
  You have been asked to pay a $960 copayment for the cardiac rehabilitation services. This item/service falls 
within the Cardiac rehabilitation services 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 cardiac rehabilitation services provided from February 7, 2022, to June 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on December 15, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye refraction. You say that you would like to be reimbursed for this service. 
The Plan denied your request. The Plan says this service was rendered by an OON provider. 
 
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. The Plan covers these services when you use a Plan-approved vision care provider. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that this service was rendered by a 
non-Plan approved provider. Based on this information, we decided that the Plan's rules for coverage of the eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction 
(92015) provided on December 15, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and an x-ray examination of the hip provided 
on June 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and an x-ray examination of the hip. You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says services from non-participating 
providers are not covered unless preauthorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit and an x-ray examination of the hip 
provided on June 14, 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 (90832), provided on June 21, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the service is medically necessary. The Plan 
denied your request. The Plan says there was no documented contact with the attending/primary care physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy (90832), provided on June 21, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the RomTech device (E1399), provided on May 12, 2022, 
through June 1, 2022. 
 
You asked the Plan to pay for the RomTech device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item does not meet the definition of DME as this item is not primarily 
and customarily used to serve a medical purpose and is useful to a person in the absence of disease. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the RomTech device (E1399), provided on May 12, 2022, 
through June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on June 22, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that the claims were originally submitted to 
Medicare and once the correct Medicare Part C plan was identified you submitted your claim to the Plan. You also state you were not aware that you needed to obtain authorization for this enrollee. The Plan denied your 
request. The Plan says enrollees must receive care from a network 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 chiropractic services provided on June 22, 2022, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that due to the enrollee's medical conditions, they are in 
need of care at an IRF. The Plan denied your request. The Plan says the IRF admission was denied as not 
meeting criteria, not medically necessary, and a lower level of care might be appropriate. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While 
the medical record supports a need for physical or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) purchased on July 18, 2022. 
 
You asked the Plan to pay for the frames. You say that you bought these glasses from a less expensive facility. 
You also say that you needed them because the glaucoma surgery you had caused a moderate decrease in your 
vision. The Plan denied your request. The Plan says you have exhausted your eyewear reimbursement benefit. 
 
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. The Plan reimburses up to $150 every two years for contact lenses and eyeglasses. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you exhausted your eyewear 
benefit on June 15, 2021. Based on this information, we decided that the Plan's rules for coverage of the frames 
have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020) purchased 
on July 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria, and their 
ongoing rehabilitation needs warrant an IRF level of care to achieve a safe and sustainable discharge. The Plan 
denied your request. The Plan says the medical necessity for admission to an IRF has not been met. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While 
the medical record supports a need for physical or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit (99336) and advanced care planning 
(99497) provided on November 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management services. You say that the medically necessary 
services were provided to the enrollee in good faith. The Plan denied your request. The Plan says the enrollee 
was referred for the services by their out-of-network living facility. The Plan says the services were not urgent 
or emergent. The Plan also says there is no network deficiency. 
 
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 services 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 these services. Therefore, we decided that the Plan does not have to pay for the domiciliary visit (99336) and advanced care planning (99497) provided on 
November 8, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service June 2, 2022. 
 
You asked the Plan to pay for procedure code 99153. You say that the medical records support the services. 
The Plan denied your request. The Plan says the rules for payment have not been met. 
 
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 99153 is a technical component only code. 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 
procedure code 99153 billed for date of service June 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital stay provided from January 19, 2022, to 
January 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an inpatient hospital stay. You say that this was medically necessary, and you are 
appealing with supporting records. 
 The Plan denied your request. The Plan says the enrollee must receive care from a network provider. 
 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an inpatient hospital stay provided from January 
19, 2022, to January 20, 2022, by an out-of-network (OON) provider.