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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing 
facility setting. Records do not document those services in the long-term care facility on a part time basis are 
not appropriate in this case. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82310, 82728, 83540, 83550, 84100) provided 
February 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for lab services (82310, 82728, 83540, 83550, 84100) provided February 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker (E0144) provided March 11, 2022. 
 
You asked the Plan to pay for the walker. You say that the walker was medically necessary. The Plan denied 
your request. The Plan says the provided walker is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that medical necessity for a walker with an enclosed 
frame (E0144) has not been established. Therefore, if an enclosed frame walker is provided, it will be denied as 
not reasonable and necessary. 
 
We looked at the file and Medicare rules. This type of walker is not covered. Based on this information, we 
decided that Medicare rules for coverage of the walker have not been met. Therefore, we decided that the Plan 
does not have to pay for a walker (E0144) provided March 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy on January 26, 2021. 
 
You asked the Plan to waive the coinsurance for chemotherapy. You say that did not like that the claim was 
reprocessed and approved because it then results in them having cost sharing applied. The Plan denied your 
request. The Plan says the cost sharing 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 20% 
coinsurance of the total cost for Medicare-covered Part B prescription drugs, including chemotherapy drugs. 
These drugs are covered under Part B of Original Medicare. Members of our plan receive coverage for these 
drugs through our plan. Covered drugs include Drugs that usually arent self-administered by the patient and 
are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center 
services. Provider billed in the amount of $114 and the allowed amount is $32.83. The Plan paid $26.26. 
$32.83 - $26.26 = $6.57. The provider also billed in the amount of $1,152 and the allowed amount $686.80. 
The Plan paid $549.44. $686.80 - $549.44 = $137.36. $6.57 + $137.36 = $143.93. Therefore, results in the total 
cost sharing amount of $143.93.   You have been asked to pay a 20% coinsurance for chemotherapy. Chemotherapy 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 
chemotherapy on January 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital stay, ER visit and inpatient 
rehab services provided from October 23, 2021, to November 9, 2021. 
 
You asked the Plan to waive the copayment for the hospital stay, ER visit and inpatient rehab services. You say 
that you did not know you would have a copayment. The Plan denied your request. The Plan says the 
copayment was applied 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 $90 
copayment per visit for emergency care. Your contract with the Plan also clearly says that you must pay a $250 
copayment per day for days 1-7 per admission for inpatient hospital care, including inpatient rehabilitation 
services. 
 
You have been asked to pay $1,840 for the hospital stay, ER visit and inpatient rehab services. The hospital 
stay and inpatient rehab services fall within the Inpatient Hospital Care benefit category. The ER visit falls 
within the Emergency Care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient 
hospital stay, emergency room (ER) visit, and inpatient rehabilitation (rehab) services provided from October 
23, 2021, to November 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for braces provided on March 23, 2022. 
 
You asked the Plan to waive the coinsurance for braces. You say that You say that you should not have to pay 
for this coinsurance as the items took so long to get to you. The Plan denied your request. The Plan says the 
coinsurance applied was 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 20% 
coinsurance for durable medical equipment (DME). The allowed amount of this item is $1,004.56 resulting in a 
coinsurance amount of $200.90 (1004.56 x 20% = $200.90). 
 
You have been asked to pay a $200.90 coinsurance for braces. Braces 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 braces provided on March 23, 2022.  
 Your complaint about the items taking too long to get to you is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on February 8, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says payment is not allowed for this service, because it was billed without a CPT/revenue code, or a 
description of the services. 
 
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 00811 is "Anesthesia for lower intestinal endoscopic 
procedures, endoscope introduced distal to duodenum; not otherwise specified." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee's diagnosis was 
reported as tubular adenoma. The record documented that this enrollee was an ASA 2 (defined as a patient with 
mild systemic disease). The gastrointestinal procedure note and the intra-operative anesthesiology record were 
not available in the records submitted. There was also no documentation in the patient's record indicating that it 
was medically necessary to have an anesthesiologist present during the colonoscopy. The documentation 
provided does not support the billing code CPT code 00811.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia services provided to the enrollee on February 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for ambulance transportation 
provided to the enrollee on December 24, 2021. 
 
You asked the Plan to waive or reduce the copayment for the ambulance transportation. You say that you feel 
some of the charges should be covered. The Plan denied your request. The Plan says the enrollee has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $295 copayment for each one-way ambulance trip.  
 
The enrollee has been asked to pay $150, which is less than the $295 copayment for the ambulance 
transportation. The ambulance transportation falls within the Ambulance Services benefit category. 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 or reduce the copayment for ambulance transportation provided to the enrollee on 
December 24, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on June 
14, 2021. 
 
You asked the Plan to waive the copayment for emergency room services. You say that after being interviewed 
by the admitting clerk at the emergency room (ER), you waited almost seven hours without being seen by a 
nurse or a physician. You also say that you asked 3 times to the admitting clerk if you were going to be seen by 
a nurse or physician soon and you were told there were no beds available in the ER. You also say that after 
waiting two to three hours more, you called your daughter to pick you up. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for emergency room services. Emergency room services fall 
within the emergency care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency 
room services provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care visit provided on March 18, 
2022. 
 
You asked the Plan to waive the copayment for a primary care visit. You say that you should not have to pay 
this copayment. The Plan denied your request. The Plan says the copayment applied was 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 $10 
copayment for Physician/Practitioner services.  
 
You have been asked to pay a $10 copayment for a primary care visit. A primary care visit falls within the 
Physician/Practitioner Services Including Doctors Office Visits 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 a primary care visit provided on March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service February 24, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code G0481. 
 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 83789 
is a column II code to column I code G0481. 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 83789 billed for date of service February 24, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99244 billed for date of service October 13, 
2021. 
 
You asked the Plan to pay for procedure code 99244. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99244 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99244 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99244 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99244 billed for date of service October 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network (OON) comprehensive 
electrophysiologic evaluation provided from March 17, 2022, to March 19, 2022. 
 
You asked the Plan to waive the coinsurance for the OON comprehensive evaluation. You say that you feel this 
should be considered an inpatient procedure with no cost. The Plan denied your request. The Plan says the 
correct coinsurance was applied. 
 
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 50% 
coinsurance for diagnostic procedures and tests at an out-of-network outpatient hospital.  
 
The file shows that the Plan verified the facility is not a network facility. Therefore, you have been asked to 
pay $8,877.64, which is less than 50% of the allowed amount for the OON comprehensive evaluation 
($24,358.73 allowed amount x 50% coinsurance = $12,179.37). You are only responsible for the lesser amount 
since you met your out-of-pocket maximum of $10,000 for the year on this claim. The OON comprehensive evaluation 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 coinsurance for an out-of-network (OON) comprehensive 
electrophysiologic evaluation provided from March 17, 2022, to March 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) leads 
provided on December 7, 2021. 
 
You asked the Plan to pay for these 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. The rules say that modifier -NU must be billed for durable medical 
equipment that is new. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required -NU 
modifier. 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 pay for the transcutaneous electrical nerve 
stimulation (TENS) leads provided on December 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection (64421) provided March 9, 2022. 
 
You asked the Plan to pay for the injection. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the code billed is not payable without a primary procedure. 
 
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 64421 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for an injection (64421) provided March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the fitness classes 
 
You asked the Plan to provide additional payment for the fitness classes purchased January 1, 2021. You say 
that you should not have been denied reimbursement for 2021. The Plan denied your request. The Plan says 
your full wellness allowance has been applied to your claim. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
up to $150 every calendar year. 
 
The Plan provided documentation showing that your $150 wellness allowance was applied to your claim. You 
have been asked to pay the remaining amount above the wellness allowance. This means you have been asked 
to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not 
have to provide additional payment for the fitness classes
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blepharoplasty. 
 
You asked the Plan to pre-approve blepharoplasty. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that blepharoplasty may be performed for functional, 
reconstructive or cosmetic purposes. Functional or reconstructive eyelid surgery is performed to improve 
abnormal function, reconstruct deformities, repair defects due to trauma or to restore normalcy to the eyelids. 
 
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 blepharoplasty. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the provided record is insufficient to 
determine whether the coverage criteria are satisfied. The elements of the coverage criteria are not satisfied. 
The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of blepharoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve blepharoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were not aware the surgical follow-up visit 
would require a referral. You say you are a veteran, and you are now cancer-free. 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. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on March 28, 2022, by an out-of-network (OON) provider.