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

 
We decided that the Plan does not have to pay for the laboratory services provided on July 12, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like for the claim to be 
reprocessed and all the lines paid at the contracted rates. The Plan denied your request. The Plan says the 
rendering and referring providers are both out-of-network providers and there was no approved authorization. 
Also, the service rendered was not urgent or emergent. 
 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 laboratory services provided on July 12, 2021, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Physical Therapy on February 17, 2021. 
 
You asked the Plan to waive the coinsurance for Physical Therapy. You say that you were unaware that your 
insurance would not cover this treatment. The Plan denied your request. The Plan says the 20% coinsurance 
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 20% 
coinsurance for Physical Therapy. The allowed amount of the injection is $65, resulting in a coinsurance 
amount of $13. 
 
You have been asked to pay 20% coinsurance for Physical Therapy. Physical Therapy falls within the 
Outpatient rehabilitation 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 coinsurance for 
Physical Therapy on February 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service November 
14, 2021. 
 
You asked the Plan to pay for procedure code 70480. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70480 is bundled into payment for 70450.  
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 70480 
is a column II code to column I code 70450. 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 70480 billed for date of service November 14, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you meet criteria for IRF. The Plan denied your 
request. The Plan says the denial of authorization for IRF service is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found while you may benefit from physical and occupational therapy, you do not need intensive therapies consisting of at least 3 hours of therapy per day for at least 5 days per week with a 
multidisciplinary approach to daily therapy. At your current level of function, your rehabilitation can be safely 
provided in a lower intensity setting such as a skilled nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the albuterol administered through a metered dose inhaler 
(code J3535) you received while in the hospital on October 18, 2021. 
 
You asked the Plan to pay for the albuterol. You say that you would like to request reimbursement for 
prescription drugs received while hospitalized. The Plan denied your request. The Plan says this drug is not 
covered under your medical benefits. 
 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 the albuterol administered 
through a metered dose inhaler (code J3535) you received while in the hospital on October 18, 2021.  
 
Benefits for the albuterol may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on September 2, 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 70450 (CT head/brain) and 70496 (computed tomography 
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with 
column I code 70496. Code 70450 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 computed tomography (CT) scan of the 
head/brain rendered on September 2, 2021.
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 the enrollee does not have documented skilled 
nursing needs or documented skilled therapy needs. The enrollee is ambulating 100 feet.  Daily skilled services 
are not required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs, custodial and intermittent, can, as a practical matter, be provided at a lower 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on 
August 20, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment for 
ambulance transport should be waived if you're admitted to the hospital. The Plan denied your request. The 
Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for Ambulance services.  
 
 
 You have been asked to pay a $200 copayment per trip for Medicare-covered ambulance benefits. The 
ambulance transport falls within the Ambulance services benefit category. You received treatment in the 
emergency room but were not admitted as an inpatient; therefore, the copayment would not be waived for 
hospital admission. 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 ambulance transport 
provided on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 19, 2021, to 
October 14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that you would like the claim to be reviewed 
and paid. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and 
there was no referral from an in-network provider or an approved authorization. Also, the services rendered 
was not urgent or emergent. 
 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 home health services provided from September 
19, 2021, to October 14, 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 laboratory services provided on October 12, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee does not have an option on 
what lab service to use. The Plan denied your request. The Plan says the rendering and referring providers are 
both out-of-network and there was no approved authorization. Also, the service rendered was not urgent or 
emergent. 
 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 laboratory services provided on October 12, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device (E0673), provided on 
June 25, 2021. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device 
(E0673), provided on June 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for a surgical injection provided on November 
4, 2021. 
 
You asked the Plan to lower the copayment for the surgical injection. You say that your copayment should only 
be for a specialist office visit and not for an outpatient facility. The Plan denied your request. The Plan says the 
proper copayment was applied for the service that was rendered by the provider. 
 
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 $150 
copayment for Medicare-covered outpatient hospital surgery services.  
 
You have been asked to pay a $150 copayment for the surgical injection. The surgical injection 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 lower the copayment for a surgical injection provided on 
November 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a wheelchair power seat elevation system. You say that the item is 
medically necessary. The Plan denied your request. The Plan says this is not a covered item as it is not 
primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrophysiologic study and catheter ablation 
services. 
 
You asked the Plan to pre-approve an electrophysiologic study and catheter ablation services. You say that the 
enrollee is at risk of stroke. The Plan denied your request. The Plan says they have no information showing that 
other means of controlling the enrollee's heart rhythm have not worked or cannot be used. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that information must be submitted to confirm that Medicare 
coverage criteria have been met. 
 
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 an electrophysiologic study and 
catheter ablation services. Our reviewer says that an electrophysiologic study and catheter ablation services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found limited records 
were provided, with an indication of an urgent need for the requested treatment due to risk of stroke. While 
there is an increased risk of stroke due to atrial fibrillation, this risk would continue even if catheter ablation 
were to be performed. There is inadequate documentation to confirm that the enrollee is an appropriate 
candidate for the requested procedures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrophysiologic study and catheter ablation services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electrophysiologic study and catheter 
ablation services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Part B drug injection provided on 
October 18, 2021. 
 
You asked the Plan to waive the coinsurance for the Part B drug injection. You say that the pharmacy advised 
you that your coinsurance would be $300.00. The Plan denied your request. The Plan says the coinsurance 
applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 
 You have been asked to pay 20% coinsurance for the Part B drug injection. The total amount allowable by the 
Plan for this injection is $2054.52. Your coinsurance is $410.90 ($2054.52 x 20%). The Part B drug injection 
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 the Part B drug injection provided on October 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a biphasic cuirass ventilator bundle. 
 
You asked the Plan to pre-approve a biphasic cuirass ventilator bundle. You say that this equipment is 
medically necessary. The Plan denied your request. The Plan says the enrollee currently has equipment that 
serves the same purpose as the requested ventilator. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a Trilogy ventilator. This device serves the same purpose as a biphasic 
cuirass ventilator bundle. No reason has been given as to why the Trilogy ventilator would not be as effective 
as the requested device. Therefore, we decided that the Plan does not have to pre-approve a biphasic cuirass 
ventilator bundle.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal ultrasound (76705) provided on November 3, 
2021. 
 
You asked the Plan to pay for an abdominal ultrasound. You say that you have provided records to support the 
level of service. The Plan denied your request. The Plan says rules for payment have not been met because the 
service at issue is included in another billed code. 
 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 76705 
is a column II code to column I code 93976. 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 an abdominal ultrasound (76705) provided on November 3, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for Intensive Care service, Emergency care 
visits and Diagnostic Lab services from April 30, 2021 to November 10, 2021. 
 You asked the Plan to waive the copayments for Intensive Care service, Emergency care visits and Diagnostic 
Lab services. You say that you do not have money for this. The Plan denied your request. The Plan says the 
copayments 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 a $325 
copayment per inpatient stay, a $90 copayment per emergency care visit, a $10 copayment per diagnostic lab 
service (per day, per facility). You have been asked to pay a total cost share amount of $545. Intensive Care 
service falls within the Inpatient Hospital care benefit category. Emergency care visits falls within the benefit 
category. and Diagnostic Lab services 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 copayments for Intensive Care service, Emergency care visits and 
Diagnostic Lab services from April 30, 2021 to November 10, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan (93880) provided on 
November 3, 2021. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that the services should be covered. 
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 $110 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
  You have been asked to pay a $110 copayment for a duplex scan. Duplex scans 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 a duplex scan (93880) provided on November 3, 2021.