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

 
We decided that the Plan does not have to pay for remote physiologic monitoring treatment management 
services provided on October 4, 2021, by an out-of-network (OON) provider. 
 
 
 You asked the Plan to pay for remote physiologic monitoring treatment management services. You say that the 
Plan is not enforcing requirements for a referral during the public health emergency. 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 
remote physiologic monitoring treatment management services at issue. We found no exception that would 
require the Plan to pay for the remote physiologic monitoring treatment management services. The records 
provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that 
the Plan does not have to pay for remote physiologic monitoring treatment management services provided on 
October 4, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heart monitor placed under the skin for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says routine implanted loop recorder implantation is not medically necessary after atrial 
fibrillation ablation. 
 
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 monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found while the patient has a history of atrial fibrillation, there is no documentation provided to suggest a 
history of unexplained syncope, cryptogenic stroke or any other apparent indication for an implanted loop 
recorder (ILR). In summary, there is insufficient documentation to support the medical necessity for insertion 
of an ILR in this patients 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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a heart monitor placed under the skin for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on December 2, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as 
you disagree with the charges and were under the impression that this was an annual physical. 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 $5 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 
  You have been asked to pay a $5 copayment for an office visit. The record indicates that multiple services were 
performed during your visit which were unrelated to your preventative exam. 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 office visit provided on December 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on August 26, 
2021. 
 
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  
 
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 the denied codes is: 
 
CPT 72052: 
 
Radiologic examination, spine, cervical; 6 or more views 
 
CPT 72082: 
 
Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views 
 
CPT 72114: 
 
Radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 views 
 
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 documentation does not 
include medical records to confirm that CPT 72082 and 72114 were performed. In terms of CPT 72052, if x-
rays are performed described by CPT 72081 - 72084 and at the same patient encounter by one or more other 
codes in code range CPT 72020 - 72120,  the total sum of the number of views and report the appropriate code 
in CPT code range CPT 72081 - 72084. (of note, radiology reports were not found in documentation), however, 
CPT 72052 would not be reported with CPT 72081. 
 
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 radiology services provided to the enrollee on August 26, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Stelara. 
 
You asked the Plan to pre-approve Stelara. You say that there should not be any delays in the enrollee's 
treatment and the drug requested is medically necessary. The Plan denied your request. The Plan says that the 
clinical documentation provided does not show that the enrollee has a diagnosis for any of the covered 
indications or the requested drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Stelara. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found the enrollee has failed Humira. The 
documentation supports that Stelara is medically reasonable and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Stelara have been met. Therefore, we decided that the Plan has to pre-approve 
Stelara.  
 
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: 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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says 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 daily 
skilled services are not necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. Although records 
document you are very limited functionally, you are not presently agreeable and cooperative with therapy 
interventions; part-time therapy in an extended care facility appears more appropriate at this time with re-
consideration of daily inpatient skilled treatment if you will participate in the future. You do not require the 
services on an inpatient basis, only in a skilled nursing facility setting. Records do not document that services 
in a 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (99285, 99053) provided on October 1, 
2020. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed for 
payment. The Plan denied your request. The Plan says this claim has been filed past the allowed 12-month 
timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services was not filed until November 3, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the medical services (99285, 99053) provided on October 1, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0427) 
provided on September 1, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered as you disagree with the charges. 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 $250 
copayment for Ambulance Services.  
 
 
  You have been asked to pay a $250 copayment for the ambulance transportation services. 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 ambulance transportation services (A0427) provided on September 
1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy performed on 
January 3, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you had a positive cologuard test 
but the colonoscopy should be covered. 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 $300 
copayment for surgery and other services.  
 
The record shows that the colonoscopy was ordered due to your positive Cologuard test. For this reason, the 
colonoscopy is considered diagnostic. Therefore, you have been asked to pay a $300 copayment for the 
colonoscopy. The colonoscopy falls within the Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers 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 diagnostic colonoscopy performed on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on October 25, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as 
you disagree with the charges. 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 $10 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 
  You have been asked to pay a $10 copayment for the office visit. The record indicates that additional services 
were performed during the preventative exam which is why the $10 copayment was assessed. 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 office visit provided on October 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiology services provided on December 
30, 2021. 
 
You asked the Plan to waive the copayment for the cardiology services. You say that the services should be 
covered as you disagree with the charges. 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 $395 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $395 copayment for cardiology services. Cardiology services fall 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 cardiology 
services provided on December 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on January 
21, 2022. 
 You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not 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, 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 the computed 
tomography (CT) scan provided on January 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GenVisc 850. 
 
You asked the Plan to pre-approve GenVisc 850. You say that you really need the shots right away, as you 
cant walk or move now. The Plan denied your request. The Plan says the requested drug is not medically 
necessary because the enrollee has not tried and failed the preferred viscosupplements for his arthritis. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. The case file shows that the Plan made reasonable attempts to obtain 
medical records.  However, medical records were not provided. Based on this information, we decided that 
there is insufficient information in the record to determine if Medicare rules for coverage of GenVisc 850 have 
been met. Therefore, we decided that the Plan does not have to pre-approve GenVisc 850.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services provided on February 3, 2022. 
 You asked the Plan to pay for the services provided. You say that the services should be paid separately. The 
Plan denied your request. The Plan says an appropriate modifier has not been 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, we have confirmed that code 77002 is a column II code to column I code 0232T. We find that 
0232T is a column II code to column I code 20610. This claim has not been billed with appropriate modifiers 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 the pain management services provided on February 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on June 22, 2021 and 
November 23, 2021. 
 
You asked the Plan to pay for the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
on June 22, 2021 and November 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular stress test (93017) provided on January 
25, 2022. 
 
You asked the Plan to pay for the cardiovascular stress test. You say that you had to have a stress test on file 
which was required by the feds. You also say that you should not be billed for this test because it has always 
been covered before. The Plan denied your request. The Plan says physical exams and other services required 
by third parties or maintaining employment are excluded and not covered under any condition. 
 
The Plan must follow Medicare rules. Medicare rules say that examinations required by third parties such as 
insurance companies, business establishments, or government agencies are excluded from coverage.  
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the cardiovascular stress test have not been met. Therefore, we decided that the Plan does not have 
to pay for the cardiovascular stress test (93017) provided on January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 17, 2021, to February 18, 2021. 
 
You asked the Plan to pay for home health services. You say that the claim was billed before to Medicare. The 
Plan denied your request. The Plan says the request for anticipated payments (RAP) was not received within 5 
calendar days from the start of care. 
 
The Plan must follow Medicare rules. The rules say that certain data elements must be completed for home 
health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. The records do not show that the RAP was 
submitted to the Plan within 5 days from the start of services. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided to the enrollee from February 17, 
2021, to February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 19, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that a referral was not obtained within the required 
timeframe. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 file shows that the enrollee was seen for a rash. 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 OON services. Therefore, we decided that the Plan does not have to pay for the office visit provided 
on October 19, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on May 14, 2021. 
 You asked the Plan to pay for the testing services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says there is no evidence to support the ordering provider was treating the 
enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The records show that the referring physician listed on the claim did not 
order the testing at issue. There are insufficient medical records to show that the testing was ordered to treat a 
specific medical problem. Based on this information, we decided that Medicare rules for coverage of the testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services 
provided on May 14, 2021.