Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for Vitamin C and Bio-Quercetin Phytosome 
purchased on January 2, 2022. 
 
You asked the Plan to reimburse you for Vitamin C and Bio-Quercetin Phytosome. The Plan denied your 
request. The Plan says Vitamin C and Bio-Quercetin Phytosome is not a covered over-the-counter supplement. 
Although Vitamin C is eligible for reimbursement, Vitamin C and Bio-Quercetin Phytosome is not due to the 
added supplement of Bio-Quercetin Phytosome. 
 
The Plan contract offers a supplemental Pick Your Perks program benefit. The benefit says over-the-counter 
items must be included on the Plans allowed items list. 
 
We looked at the file and the Plans rules. The file shows that Vitamin C and Bio-Quercetin Phytosome is not a 
covered over-the-counter supplement under the Pick Your Perks benefit. Therefore, we decided that the Plan 
does not have to reimburse you for Vitamin C and Bio-Quercetin Phytosome purchased on January 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery on November 17, 2021 
 
You asked the Plan to waive the copayment for cataract surgery. You say that there was an issue with the first 
surgery and you shouldn't be responsible for the second surgery. The Plan denied your request. The Plan says 
the copayment you are being charged 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 a $350 
copayment for cataract surgery at an outpatient hospital setting.  
 
You have been asked to pay a $350 copayment for cataract surgery. Cataract surgery falls within the Outpatient 
hospital 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 cataract surgery on 
November 17, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator for the enrollee. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no documentation of prior spine surgery or failed fusion. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
 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 stimulator. Our reviewer says that 
the requested stimulator is not medically reasonable or necessary. Our physician reviewer found the provided 
records do not document multi-level spinal fusion surgery or failed fusion, where a minimum of 9 months have 
elapsed since the last surgery, as required. 
 
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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bone growth stimulator for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation oncology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON radiation oncology services. You say that you need radiation 
therapy for your liver cancer. The Plan denied your request. The Plan says there are network providers who can 
supply the services needed. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve OON care. Therefore, we decided that the Plan does not have to pre-approve radiation 
oncology services to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on October 27, 
2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the claim should be paid. 
The Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as 
it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 18, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital 
care (99223) provided on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services at an endoscopic carpal tunnel 
release (29848) provided on May 24, 2021. 
 
You asked the Plan to pay for surgical assistant services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 29848. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for 
surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for 
surgical assistant services at an endoscopic carpal tunnel release (29848) provided on May 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 27, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection rendered on July 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 64421 (intercostal nerve injection) and 11971 (removal of 
tissue expander without insertion of implant). Code 64421 is a column II code with a modifier indicator of 1 
when billed with column I code 11971. Code 64421 was not billed with an appropriate modifier to allow for 
separate payment. Therefore, we decided that the Plan does not have to pay for the injection rendered on July 
21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the removal of impacted ear wax (69209) 
provided on November 18, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $5 
copayment for an office visit with a primary care physician (PCP)/other healthcare professionals.  
 
 You have been asked to pay a $5 copayment for an office visit provided. On this day, you had an annual 
wellness visit in which a $0 copayment was applied for this service. However, on this day you additionally had 
ear wax removed which is not part of an annual wellness visit. An office visit copayment is applicable for this 
type of service. 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 the removal of impacted ear wax (69209) 
provided on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intravenous tubing extension set (S1015) and infection 
control supplies (S8301) provided on September 10, 2021. 
 
You asked the Plan to pay for an intravenous tubing extension set and infection control supplies. You say that 
the items at issue allow you to perform procedures with the same level of quality and safety as an ambulatory 
surgical center or hospital but at a much lower overall cost. The Plan denied your request. The Plan says 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. 
 
 
 
 Codes S1015 and S8301 have a status indicator of I on the Physician Fee Schedule. This means that codes 
S1015 and S8301 are invalid for Medicare billing purposes. Based on this information, we decided that 
Medicare rules for coverage of an intravenous tubing extension set and infection control supplies have not been 
met. Therefore, we decided that the Plan does not have to pay for an intravenous tubing extension set (S1015) 
and infection control supplies (S8301) provided on September 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network 
(OON) provider on November 1, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 services 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 laboratory services rendered by the out-of-network (OON) provider on 
November 1, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for medical imaging services rendered on August 6, 2021. 
 
You asked the Plan to pay for medical imaging services. You say that there should be two different claims for 
two different facilities. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided documentation of initial payment, 
corrected claim, or reprocessed claim. It is the responsibility of the Plan to substantiate its denial rationale., In 
this case the available case record does not substantiate the Plan's denial; therefore, we must find in your favor. 
Therefore, we decided that the Plan has to pay for medical imaging services rendered on August 6, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on October 15, 2021.
  
 
You asked the Plan to waive the copayment for the x-ray. You say that the services should be covered as you 
feel you were mislead. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 
the services provided. 
 
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 $125 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
  You have been asked to pay a $125 copayment for the x-ray. X-rays fall 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 an x-ray provided on October 15, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
criteria. 
 
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 
service is medically necessary. Our physician reviewer found you do not have documented skilled nursing 
needs. You do have documented skilled therapy needs. You are improving and are not yet shown to have 
reached a plateau in function. Daily skilled services are reasonably required to improve your strength and 
endurance, to establish a maintenance program and/or to prevent deterioration of your condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
 
 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 3D (three-dimensional) imaging of the heart by using 
a high-energy CT (Computed tomographic) scanner (SPECT). (78452). 
 
You asked the Plan to pre-approve myocardial perfusion imaging. You say that these are tests that you need 
and they keep getting denied. You doctors are requesting them and you have COPD. The Plan denied your 
request. The Plan says medical necessity has not been established for the requested services. 
 
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 myocardial perfusion imaging. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while the enrollee may be a candidate for a stress test she has no history of 
atypical chest pain, MI, or other symptom suggestive of coronary heart disease. She has some dyspnea on 
exertion, but she is a smoker and has COPD.  There is no report in the chart of prior nuclear medicine or stress 
echo test. The justification for cardiac SPECT CT has not been established in the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a 3D (three-dimensional) imaging of the heart by using a high-energy CT 
(Computed tomographic) scanner (SPECT). (78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left heart catheterization for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show that it is medically reasonable to pursue cardiac 
catheterization at this time in the work up of the chest discomfort issue, without other less invasive testing. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has had several episodes of chest pain and multiple comorbidities. A stress test has 
not been performed. The documentation does not support the rationale for this invasive imaging study. The 
guidelines do not support a need for cardiac catheterization in this setting. As a result, at this time cardiac 
catheterization would not be considered medically appropriate and necessary in this enrollee's clinical 
management. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a left heart catheterization for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 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 June 18, 2021.