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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 1, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that this service was billed appropriately. 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 December 1, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 10, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sends the specimens 
to your laboratory to process, and you would like the claim to be paid. The Plan denied your request. The Plan 
says the rendering and referring providers are both OON 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 March 10, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar injection services provided on January 28, 2022. 
 You asked the Plan to pay for the services provided. You say that the medical records support the charges. The 
Plan denied your request. The Plan says the code was not billed in accordance with guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar 
injection services provided on January 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) on 
January 19, 2022. 
 
You asked the Plan to waive the copayment for magnetic resonance imaging (MRI). You say that you would 
like to appeal the cost share. 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 magnetic resonance imaging (MRI).  
 
You have been asked to pay a $200 copayment for magnetic resonance imaging (MRI). Magnetic resonance 
imaging (MRI) falls within the Diagnostic Services, Labs and Imaging 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 magnetic resonance imaging (MRI) on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 27, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 laboratory services at issue in this appeal. The Plan did not pre-approve 
the laboratory services 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 laboratory services provided on 
January 27, 2022, 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 services provided on July 17, 2020. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says the services do not meet coding 
standards. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 
the lab services provided on July 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair van transportation provided on February 28, 
2022. 
 
You asked the Plan to pay for the wheelchair van transportation. You say that this should be a medically 
necessary transportation cost and should be covered by the Plan. The Plan denied your request. The Plan says 
wheelchair van transportation is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the wheelchair van transportation provided on February 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
March 18, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you feel you should not be 
responsible since you slipped on the hospital floor and caused injuries. 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 $120 
copayment for each emergency room visit.  
 
You have been asked to pay a $120 copayment for the ER visit. 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 emergency room (ER) visit 
provided on March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility services provided on February 4, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility services. You say that it is the facilities responsibility to 
obtain the proper authorization and it was medically necessary to treat the enrollee. The Plan denied your 
request. The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an 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 nursing facility services provided on February 
4, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for CPAP equipment and supplies provided on 
February 4, 2022. 
 
You asked the Plan to waive the deductible for CPAP equipment and supplies. You say that the face mask 
wasn't needed, and you dont want to pay for things you dont need. The Plan denied your request. The Plan 
says the deductible applied is correct. 
 
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 $300 deductible which applies to Durable Medical Equipment (DME) 
and Related Supplies.  
 
 
 
 
 
 
 
 
 
 The item or service you asked the Plan to waive the deductible for falls within the benefit category Durable 
Medical Equipment (DME) and Related Supplies. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is $300 deductible which applies to Durable Medical Equipment (DME) and Related 
Supplies. This cost sharing is a contractual obligation that had not been met at the time CPAP equipment and 
supplies was received on February 4, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for CPAP equipment and supplies provided on February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and the coinsurance for an endoscopy with 
biopsy, an office visit, a midazolam hydrochloride injection, and a fentanyl citrate injection provided from 
January 3, 2022, to January 17, 2022.  
You asked the Plan to waive the copayment and the coinsurance for an endoscopy with biopsy, an office visit, a 
midazolam hydrochloride injection, and a fentanyl citrate injection. You say that this provider has been your 
primary care provider for 30 years. You also say that he takes care of all of your needs. You also say he is the 
only provider you see. 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 20% for 
all Medicare-covered Part B drugs other than Medicare-covered Part B allergy antigens. Your contract with the 
Plan also says that enrollees must pay a $110 copayment for Medicare-covered radiological diagnostic services, 
not including x-rays, performed in a physician's office or at a free-standing facility. Your contract with the Plan 
also says that diagnostic radiology services require specialized equipment beyond standard x-ray equipment 
and must be performed by specially trained or certified personnel, including an MRI. Your contract with the 
Plan also says that enrollees must pay a $35 copayment for services obtained from a specialist.  
 
You have been asked to pay $.26 in coinsurance, which is 20% of the allowed amount for a midazolam 
hydrochloride injection ($1.30 allowed amount x 20% coinsurance = $.26). You have also been asked to pay 
$.25 in coinsurance, which is 20% of the allowed amount for a fentanyl citrate injection ($1.26 allowed amount 
x 20% coinsurance = $.25).  A midazolam hydrochloride injection and a fentanyl citrate injection fall within 
the Medicare Part B Prescription Drugs benefit category. You have also been asked to pay $35, which is less 
than the $110 copayment for an endoscopy with biopsy. An endoscopy with biopsy falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also been asked to pay a 
$35 copayment for an office visit. An office 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 and the 
coinsurance for an endoscopy with biopsy, an office visit, a midazolam hydrochloride injection, and a fentanyl 
citrate injection provided from January 3, 2022, to January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on February 14, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for chiropractic services. You say that the provider and referring providers are 
participating providers with Medicare. The Plan denied your request. The Plan says the enrollee went to an out-
of-network provider and services 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 chiropractic services provided on February 14, 
2022, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an at-home nebulizer provided on 
September 20, 2020. 
 
You asked the Plan to waive the coinsurance for an at-home nebulizer. You say that you were not informed of 
the coinsurance for this item. 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) and related supplies. The allowed amount of this DME is 
$12.17 resulting in a 20% coinsurance amount of $2.43 ($12.17 x 20% = $2.43). 
 
You have been asked to pay $2.43 coinsurance for an at-home nebulizer. An at-home nebulizer 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 an at-home nebulizer provided on September 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the admission to the 
LTACH with medical records. The Plan denied your request. The Plan says the enrollee's condition is not 
stable enough for transfer to LTACH and current care needs would be better met in the acute hospital setting. 
The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and 
there are no issues for which LTACH may offer a therapeutic advantage. 
 
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 that the enrollee appears to still be somewhat unstable and should only require short-
term additional acute care services that can be safely administered at the current facility until more stable and 
appropriate for a lower level of care. 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. Transfer to LTACH is not medically necessary at this time as the enrollee is not yet stable for 
transfer and as it would not be clinically advantageous. Completion of treatment at the current facility is 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on February 23, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for chiropractic services. You say that the provider and referring providers are 
participating providers with Medicare. The Plan denied your request. The Plan says the enrollee went to an out-
of-network provider and services 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 chiropractic services provided on February 23, 
2022, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Unna boot strapping provided on March 10, 2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee has bilateral edema. The Plan 
denied your request. The Plan says the service was not billed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 29580 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the Unna 
boot strapping provided on March 10, 2022.
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 SNF care is medically necessary. The Plan denied 
your request. The Plan says documentation from the hospital shows a decline in the enrollee's progress from 
when he was admitted and he refuses to participate in therapy sessions. 
 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 
skilled nursing facility (SNF) care is not medically necessary. Our physician reviewer found that the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on April 28, 2022, 
by an OON provider. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that you are appealing and request a 
reconsideration of the denied charges. The Plan denied your request. The Plan says the out-of-network services 
were not authorized. 
 
 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 a hospital outpatient clinic visit provided on April 
28, 2022, by an OON provider.