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

 
We decided that the Plan does not have to pay for procedure codes 75726 and 75774 billed for date of service 
July 15, 2021. 
 
You asked the Plan to pay for procedure codes 75726 and 75774. You say that the patient had multiple exams 
on this date of service. The Plan denied your request. The Plan says payment for codes 75726 and 75774 is 
bundled into payment for code 37244. 
 
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 75726 
and 75774 is a column II code to column I code 37244. 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 codes 75726 and 75774 billed for date 
of service July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92012) provided on January 20, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that you feel this should be covered because you have 
been going to this provider for years, and the Plan paid for an eye exam for with the same provider on October 
25, 2021. The Plan denied your request. The Plan says this service was rendered by an OON provider. The Plan 
also says that the treating provider is no longer contracting with the Plan as of August 11, 2021. 
 
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 
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 eye exam (92012) provided on January 20, 
2022 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care. 
 
You asked the Plan to pre-approve home health care. You say that the enrollee cannot drive and would greatly 
benefit from home health. The Plan denied your request. The Plan says the denial of authorization for home 
health care is correct. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health care. Our reviewer says 
that the enrollee does not meet the Medicare criteria for home health care. Our physician reviewer found the 
enrollee does not have documented skilled needs. The enrollee does not have a documented acute illness or 
injury, rather has chronic arthritis with custodial needs. As such, home health services are not shown to be 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health care.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 with the comorbid conditions being stable, the enrollee does not need PM&R 
physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute 
exacerbations of chronic medical conditions. The enrollee does not need intensive therapies, consisting of at 
least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. The 
enrollee's rehab needs can be safely met in an alternate and lower intensity setting such as in-home with 
services. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the duplex scan services received on April 
5, 2021, the two ultrasound services received on July 19, 2021, and the two computed tomography services 
received on August 5, 2021 
 
You asked the Plan to waive the copayments for the duplex scan services, the two ultrasound services, and the 
two computed tomography services. You say that you disagree with the amount owed for these copayments. 
The Plan denied your request. The Plan says the claims have been processed correctly per your plan benefits. 
 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 outpatient diagnostic tests.  
 
You have been asked to pay a $5 copayment for each of the duplex scan services and the two ultrasound 
services. You have been asked to pay an $80 copayment for each of the two computed tomography services. 
The duplex scan services, the two ultrasound services, and the two computed tomography services fall within 
the outpatient diagnostic tests 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 the duplex 
scan services received on April 5, 2021, the two ultrasound services received on July 19, 2021, and the two 
computed tomography services received on August 5, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 13, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services can be received in-network. 
 
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 an office visit provided on December 13, 2021 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 right lateral sacral branch radiofrequency ablation (RFA). 
 
You asked the Plan to pay for the RFA. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
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 pay for the RFA. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that RFA of the lateral sacral branches is considered experimental/investigational because of the wide 
variation in efficacy reported in the peer reviewed literature. Therefore, this request is not medically reasonable 
or necessary. 
 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pay for the right lateral sacral branch radiofrequency ablation (RFA).
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 need IRF level of care. 
 The Plan denied your request. The Plan says you do not meet criteria for admission to an IRF. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sacroiliac joint radiofrequency ablation provided to the 
enrollee on September 8, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says radiofrequency ablation used for sacro-iliac joint pain is considered not medically 
necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered an experimental/investigational procedure because of the wide variation in efficacy 
reported in the peer reviewed literature. Therefore, the procedure was not medically necessary or reasonable.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for sacroiliac joint radiofrequency ablation provided to the enrollee on September 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
   
We reviewed the file and the Medicare rules. We find that based on the medical records the enrollee does not 
have a tobacco smoking history of at least 30 pack-years, and is not a current smoker or former smoker who 
quit within the last 15 years. Therefore, we decided that the Plan does not have to pre-approve a low dose 
computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 2, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the coverage for this procedure 
was denied and you would like the Plan to reconsider paying for it. The Plan denied your request. The Plan 
says the procedure was not denied, and the proper copayment was applied since the allowed amount was less 
than the copayment 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 $160 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility. The total allowed amount for the ultrasound was $150.84 which 
is less than the copayment amount of $160. Therefore, $150.84 was charged as the copayment amount. 
 
  You have been asked to pay a $150.84 copayment for the ultrasound. The ultrasound 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 copayment for an ultrasound provided on March 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray provided on February 10, 2022. 
 
You asked the Plan to waive the copayment for the x-ray. You say that this was a preventive procedure and 
there should not be 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 $35 for 
each outpatient x-ray, diagnostic procedure, and test.  
 
You have been asked to pay $35 for the x-ray. The x-ray 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 copayment for 
the x-ray provided on February 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on February 
9, 2022. 
 
You asked the Plan to waive the copayment for a cystourethroscopy. You say that you are seeking the 
copayment of $0 instead $295. The Plan denied your request. The Plan says you have been charged the correct 
copayment 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 $295 
copayment for each Medicare-covered in-network outpatient hospital facility visit.  
 You have been asked to pay a $295 copayment for a cystourethroscopy. The cystourethroscopy 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 cystourethroscopy 
provided on February 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional reimbursement for a wheelchair provided by an 
out-of-network (OON) provider on November 22, 2021. 
 
You asked the Plan to provide additional reimbursement for the wheelchair. You say that you feel the 
reimbursed amount is incorrect. The Plan denied your request. The Plan says the correct amount was 
reimbursed. 
 
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 30% 
coinsurance for durable medical equipment (DME) from an out-of-network provider. 
 
Item Allowed Amount Provider Responsibility Your Responsibility 
Wheelchair (E1399) $107.41* $75.19 (70%) $32.22 (30%) 
 
* Note  The Plan cannot reimburse any amount in excess of allowed amount, even if the actual charged 
amount is higher. The file shows that the Plan has reimbursed a total of $75.19, which is the Plans responsibility of 70% of the 
allowed amount for the wheelchair. The wheelchair falls within the Durable Medical Equipment (DME) and 
Related Supplies benefit category. This means that you have been reimbursed 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 provide additional reimbursement for a wheelchair 
provided by an out-of-network (OON) provider on November 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine 
transportation. 
 
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you need additional 
mileage to get to a scheduled surgery. The Plan denied your request. The Plan says that each one-way trip must 
not exceed 50 miles of driving distance. 
 
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits, 
they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we 
decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram provided on January 
7, 2022. 
 
You asked the Plan to waive the copayment for an electrocardiogram. You say that you only receive $1000 
monthly through Social Security and you cannot afford your medical expenses. The Plan denied your request. 
The Plan says you have been charged the correct copayment 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 $30 
copayment per day for Medicare-covered outpatient diagnostic tests. You will only pay one copayment per day 
even if multiple labs are performed.  
 
 
 
 You have been asked to pay a $30 copayment for an electrocardiogram. The electrocardiogram 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 copayment for an electrocardiogram provided on January 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine ophthalmological examination including 
refraction (S0620) provided on February 22, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the routine ophthalmological exam. You say that this was a routine vision exam 
and should be covered. The Plan denied your request. The Plan says you must use network providers to get 
your medical care and services. The Plan also says that you received this service from an OON provider. 
 
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 
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 routine ophthalmological examination 
including refraction (S0620) provided on February 22, 2022 by an out-of-network (OON) provider.