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

 
We decided that the Plan does not have to pay for the genetic testing provided on October 28, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the genetic testing. You say that the genetic testing was provided due to an 
emergency. The Plan denied your request. The Plan says the 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 genetic testing provided on October 28, 2021, 
by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tendon graft (20924) provided on October 18, 2021. 
 
You asked the Plan to pay for the tendon graft (20924). You say that this code is clearly documented in the 
office note and the claim should be reprocessed for payment. The Plan denied your request. The Plan says 
procedure code 20924 is not supported by the medical records submitted. 
 
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 20924 is tendon graft, from a distance (eg, palmaris, toe 
extensor, plantaris). 
 
 
  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the tendon graft (20924). Our reviewer says that this does not 
meet the criteria for coverage. Our reviewer found that the operative report does not support tendon graft from 
a distance. The operative report describes a tendon transfer, as the tendon remained intact with its native 
muscle. Therefore, this procedure code cannot be verified by the operative report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the tendon graft (20924) have not been met. Therefore, we decided that the Plan 
does not have to pay for the tendon graft (20924) provided on October 18, 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 is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that you 
meet criteria for SNF coverage. Our physician reviewer found you do not have documented skilled nursing 
needs. You do have documented skilled therapy needs. The documentation does not yet show that you have 
reached a plateau in function. Strength and endurance training are medically necessary and reasonable. Daily 
skilled services are required to establish a maintenance program, prevent deterioration of your condition and 
ensure your safety. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and chiropractic manipulation treatment 
provided on November 17, 2021 and November 19, 2021. 
 
You asked the Plan to pay for chiropractic services. You say that you were not told you would be charged this 
amount. The Plan denied your request. The Plan says the copayment amounts you are being charged are 
correct, and the denial of payment for an office visit charge is correct because this is not covered when 
performed by a chiropractor. 
 
 
 
 
 
 
 
 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. Enrollees must pay $20 copayment for each covered 
chiropractic visit. 
 
The records show that the office visit service at issue is not manual manipulation of the spine. Additionally, 
you received 2 covered visits for manual manipulation of the spine, resulting in a copayment amount of $40. 
Therefore, we decided that the Plan does not have to pay for an office visit and chiropractic manipulation 
treatment provided on November 17, 2021 and November 19, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
on February 23, 2022 after a motor vehicle collision and resulting traumatic brain injury. She was discharged to 
an inpatient rehabilitation facility (IF) on April 16, 2022. She has no skilled nursing needs. She is ambulating 
more than 100 feet and tending to activities of daily living with minimal supervision. She does not require 
skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an 
inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient detoxification hospital care. 
 
You asked the Plan to pre-approve inpatient detoxification hospital care. You say that releasing the enrollee 
before transfer to a rehab facility will cause the enrollee to relapse for substance abuse. The Plan denied your 
request. The Plan says that the request is not medically necessary. 
 
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. Therefore, we decided that the Plan has to pre-approve inpatient detoxification 
hospital 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit on December 3, 
2021. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that the enrollee was not seen 
in the emergency room. You say that the enrollee was seen in the waiting room. The Plan denied your request. 
The Plan says the copayment 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). The enrollees contract with the Plan clearly says that enrollee must 
pay $90 copayment for each emergency room visit.  
 
The enrollee has been asked to pay $90 copayment for the emergency room visit. The emergency room visit 
falls within the Emergency Care benefit category. The records show the enrollee was seen in the emergency 
room. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit on 
December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the provision of test materials and 
equipment for home INR monitoring (G0249) provided on July 22, 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 $35 
copayment for physician specialist services (including surgery second opinion, telehealth, and urgently needed 
services).  
 You have been asked to pay a $35 copayment for the physician specialist services provided. 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 provision of test materials and equipment for home INR 
monitoring (G0249) provided on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on 
January 5, 2022. 
 
You asked the Plan to pay for the first intraoral periapical x-ray. You say that you should not be responsible for 
the $225.00 payment. The Plan denied your request. The Plan says your benefits for this service have been 
satisfied and the frequency limitation has been exceeded. 
 
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, intraoral x-rays are limited to 1 
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) 
on January 12, 2022 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the first intraoral periapical x-ray (D0220) provided on January 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a computed tomography (CT) scan of the 
heart provided on October 14, 2021. 
 
You asked the Plan to waive the deductible for a computed tomography (CT) scan of the heart. You say that 
you paid the copayment and the balance due form the provider was not paid. You also say you received a final 
past due notice from the provider on January 5, 2022. The Plan denied your request. The Plan says you were 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
You have been asked to pay $141.48 for a computed tomography (CT) scan of the heart. A computed 
tomography (CT) scan of the heart falls within the benefit category outpatient diagnostic tests and therapeutic 
services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$500 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time a computed tomography (CT) scan of the 
heart was received on October 14, 2021. Therefore, we decided that the Plan does not have to waive the 
deductible for a computed tomography (CT) scan of the heart provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99335) rendered by the out-of-network (OON) provider on  
December 16, 2021. 
 
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 the service was 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 service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99335) rendered by the out-of-network (OON) provider on December 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections of hyaluronan (a Medicare Part 
B prescription drug) provided on October 29, 2021 and November 5, 2021. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you wish to contest these charges. 
The Plan denied your request. The Plan says the coinsurance amounts you are being charged are 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 Medicare Part B prescription drugs. The allowed amounts of these drugs total $719.10, 
resulting in a total coinsurance amount of $143.82. 
 
You have been asked to pay 20% coinsurance for Part B drugs. Part B drugs fall 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 injections of 
hyaluronan (a Medicare Part B prescription drug) provided on October 29, 2021 and November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames and progressive lenses provided on 
December 9, 2021. 
 
You asked the Plan to pay for the provided features. You say that you pay more out-of-pocket than the Plan 
ever paid you. The Plan denied your request. The Plan says the items are non-covered. 
 The Plan must follow Medicare rules. The rules say that lenses and frames are only covered under certain 
medical indications.  
 
We looked at the file and the rules. The frames and lenses you received are non-covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the deluxe frames and progressive lenses provided 
on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87801 and 87150) provided on 
November 15, 2021. 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 laboratory 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 the laboratory services (87801 and 87150) provided on November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for end-stage renal disease (ESRD) treatment 
services provided on October 1, 2021. 
 
You asked the Plan to waive the coinsurance for the ESRD treatment. You say that you feel you had already 
met your yearly maximum. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing 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 a 20% 
coinsurance for each treatment.  
 
The file shows that at the time the claim was submitted, you had a total of $33.60 remaining to meet your 
$3,000 maximum out-of-pocket (MOOP) expenses. This amount was applied for the services received on October 1, 2021. Please note that cost sharing amounts are applied to the maximum in the order in which the 
claims are received and processed by the Plan. The ESRD treatment falls within the Services to Treat Kidney 
Disease 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 end-stage renal disease 
(ESRD) treatment services provided on October 1, 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 the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided the enrollee only requires short-term additional 
acute care services that can safely be administered at the current facility. The enrollee does not require services 
at the LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five (5) (CPT code 99214). 
 
You asked the Plan to pre-approve the office visits. You say that you are appealing the denial of medical 
coverage for your TMJ because it is a medical condition. You state that your jaw has been out of joint 
(misaligned) since December 4, 2021, and it has been hard to chew, plus there is sometimes pain with chewing. 
The Plan denied your request. The Plan says they are approving coverage for an initial visit to this facility for 
the clarification of the diagnosis and cause, of your symptoms.  The Plan states based on the findings of that visit, further treatment could be requested from your provider, if appropriate per Medicare criteria. The Plan states any further treatment is subject to pre-authorization with the health plan. 
 
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 office visits. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found only one (1) appointment is reasonable and medically necessary and the other five (5) visits 
cannot be justified as there is no documented note from the specialist dictating a medical plan that would 
require multiple follow-ups. Following the initial visit, follow-up visits may be reconsidered. 
 
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 office visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve five (5) (CPT code 99214).