Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment on September 29, 
2021. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says the cost share applied is correct. 
 
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 oxygen equipment. The allowed amount of the oxygen equipment is $282.25, resulting in a 
coinsurance amount of $56.44. 
 
You have been asked to pay 20% coinsurance for oxygen equipment. Oxygen equipment falls within the 
Durable medical equipment (DME) and related supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for oxygen equipment on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on 
November 18, 2021. 
 
You asked the Plan to pay for the moderate sedation services (99153). You say that all supporting documents 
are attached, and the claim should be processed. The Plan denied your request. The Plan says procedure code 
99152 for has been overturned. The Plan also says procedure code 99153 is not separately payable when 
performed by a physician in a facility setting. 
 
The Plan must follow Medicare rules. Medicare rules say that carriers may not pay for the technical component 
(TC) of radiology services furnished to hospital patients.  
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the moderate sedation services (99153) have not been met. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Therefore, we 
decided that the Plan does not have to pay for the moderate sedation services (99153) provided on November 
18, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on January 18, 2019. 
 
You asked the Plan to pay for the drug testing provided. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the service 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 
code G0480 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0480 is supported in the medical record. Specifically, the lab report clearly shows that 
1-7 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Also, the record indicates that this provider was directed by the Plan to not 
obtain records. With this direction, it is inappropriate for the Plan to deny these services based on the physician 
signature. Based on this information, we decided that Medicare rules for coverage of the drug testing provided 
have been met. Therefore, we decided that the Plan has to pay for drug testing provided on January 18, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound provided on January 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the ultrasound. You say that the ultrasound was medically necessary. The Plan 
denied your request. The Plan says the provider was 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 
ultrasound. We found no exception that would require the Plan to pay for the ultrasound. The records provided 
for review do not show that the ultrasound was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the ultrasound provided on January 11, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 5, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that this should be covered 
because this was a medical doctor ordered COVID-19 test and there should be no copayment. You say there 
were no other services. The Plan denied your request. The Plan says you have been charged the correct 
copayment amount. 
 
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 $30 
copayment for each Medicare-covered urgent care facility visit. This copayment is not waived if you are 
admitted as an inpatient to the hospital within 24 hours for the same condition.  
 
  
You have been asked to pay $30 copayment for an urgent care visit. The urgent care visit falls within the 
Urgently needed 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 copayment for an urgent 
care visit provided on January 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stab phlebectomy of varicose veins, 1 extremity; 10-
20 stab incisions (37765). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet 
the medically necessary criteria outlined in the Medicare criteria for coverage. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has bilateral lower extremity venous insufficiency with varicose veins 
and pain. The health plan has already approved bilateral greater saphenous vein and right small saphenous vein 
ablation. These have not yet been performed.  Additionally, the documentation describes the tributary veins as 
being approximately 2 mm in diameter bilaterally. The health plan policy requires that for stab phlebectomy to 
be covered, associated truncal reflux is either not present or treated and, despite this and despite continued 
conservative therapy, the patient remains symptomatic with greater than 4 mmHg tributaries.  A rationale for 
this policy is that many patients will experience satisfactory resolution of their symptoms with the endovenous 
treatments alone, particularly if the tributary veins are small.  
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions (37765).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistant services provided on October 20, 2021. 
 
You asked the Plan to pay for the surgical assistant services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the surgical assistant services 
provided on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on January 24, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and laboratory work provided on February 14, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and the laboratory work. You say that the services were medically 
necessary. The Plan denied your request. The Plan says no prior authorization was 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
office visit and the laboratory work. We found no exception that would require the Plan to pay for the office 
visit and the laboratory work. The record shows CPT code 36415 was billed which means the provider had the 
opportunity to confirm insurance coverage and authorization. Therefore, we decided that the Plan does not have 
to pay for the office visit and laboratory work provided on February 14, 2022, by an out-of-network (OON) 
provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility stay provided on May 1, 2020, to 
May 18, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the skilled nursing facility stay. The Plan denied your request. The Plan says 
these services were provided out-of-network and 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 the skilled nursing facility stay provided on May 
1, 2020, to May 18, 2020, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B medication on January 4, 2022. 
 
You asked the Plan to waive the coinsurance for Part B medication. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says the cost share applied is correct. 
 
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 Part B medication. The claim for services received on January 4, 2022 has an allowed amount 
of $10,963.08, with a member responsibility of 2,192.62. The claim for services received on February 1, 2022 
has an allowed amount of $10,963.08, with a member responsibility of $1463.95 which is less than 20% 
because the member met their maximum out-of-pocket. The total allowed amount is $3,656.57. 
 
You have been asked to pay 20% coinsurance for Part B medication. Part B medication falls within the 
Medicare Part B prescription drugs 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 
Part B medication on January 4, 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 rehabilitation was working to build the enrollee's 
overall strength. The Plan denied your request. The Plan says the denial of authorization for 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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach with rehabilitation care.  While the record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. there is not a reasonable expectation that the enrollee will be able to fully 
participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on January 
18, 2022. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that this fee is in addition to the 
primary anesthesia procedure and is separately payable based on ASA guidelines. You say that the attached 
description of the service documents the qualifying circumstances that enable this code to be paid. The Plan 
denied your request. The Plan says bundled services are not eligible for separate reimbursement. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on January 18, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on April 10, 2017. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the service 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 
code G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Additionally, the Plan has not forwarded any evidence to support why CPT code 
80307 is not eligible for payment. It is the burden of the Health Plan to substantiate their denial with evidence. 
In this case, the Plan's denial has not been substantiated so we must find in your favor. Also, the record 
indicates that this provider was directed by the Plan to not obtain records. With this direction, it is inappropriate 
for the Plan to deny these services based on the physician signature. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have been met. Therefore, we decided that the Plan has to pay 
for the drug testing provided on April 10, 2017.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 meets the criteria for coverage and their 
needs cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says the records 
do not show that the enrollee needs to be seen by a rehabilitation doctor at least 3 times a week for evaluation 
of functional and medical goals and progress. The Plan says that the records do not show that the enrollee 
needs an intensive team for care. The Plan says that the services needed can be provided safely in other 
settings. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for hip replacement surgery and acute kidney injury. The enrollee's medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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.