Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 25, 
2022, through April 26, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the requested inpatient care was 
medically reasonable and necessary. The Plan denied your request. The Plan says an ambulatory surgery level 
of care was more appropriate in this case. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review indicates that the enrollee presented to the emergency department on April 
25, 2022, with chest pain. He was evaluated and treated with aspirin and Plavix. He underwent cardiac 
catheterization and had a stent placed. He tolerated the procedure without complication, was monitored and 
discharged home on April 26, 2022. The review has determined that the record did not show that at the time of 
inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care 
(including earlier emergency department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from April 25, 2022, through April 26, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Medtronic Infuse BMP-2 Allograft for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Medtronic Infuse BMP-
2 Allograft in the setting of posterior spinal fusion surgery has not been demonstrated in the peer-reviewed 
literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is limited 
published, large-scale, long-term peer-reviewed literature that shows Medtronic Infuse BMP-2 Allograft to be 
an effective and/or safe treatment for the enrollee's pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Medtronic Infuse BMP-2 Allograft for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal system, below knee, flexible 
protective outer surface covering system (L5962) 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs this cover because she lives 
near a beach. The Plan denied your request. The Plan says that there is no documentation that supports that the 
member's activity subjects her prosthesis to harsh environmental situations or that she engages in any 
extraordinary activities that would justify the need for extra protection with a flexible outer surface covering 
system. 
 
The Plan must follow Medicare rules. Medicare rules say that the protective outer surface covering system is 
used by a beneficiary who has special needs for protection against unusually harsh environmental situations.  
 
We looked at the file and Medicare rules. The record does not show the enrollee is subject to harsh 
environmental situation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an addition, 
endoskeletal system, below knee, flexible protective outer surface covering system (L5962)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 9, 
2022 to March 26, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 9, 2022 to March 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility stay from 
February 9, 2022, to February 19, 2022. 
 
You asked the Plan to waive the copayment for a skilled nursing facility stay. You say that you don't believe 
you were there for ten days, and want the payment lowered. The Plan denied your request. The Plan says the 
copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20 per 
day, for days 1 to 20 for skilled nursing facility (SNF) care ($20 per day for days 1 to 20 x 10 days = $200). 
 
You have been asked to pay $200 per day, for days 1 to 20 for a skilled nursing facility stay. A skilled nursing 
facility stay falls within the Skilled Nursing Facility (SNF) 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 a skilled nursing facility stay from February 9, 2022, to February 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve after cataract surgery care to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve after cataract surgery care. You say that the services should be covered. The 
Plan denied your request. The Plan says the service can be provided by an in-network 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
after cataract surgery care to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an influenza vaccine provided on October 12, 2021. 
 
You asked the Plan to pay for an influenza vaccine. You say that the claim was denied because the supporting 
documentation was missing. You also say that you have included the documentation. The Plan denied your 
request. The Plan says the member submitted a claim for reimbursement with incomplete and/or incorrect 
information and did not provide proof of payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an influenza vaccine have been met. 
Specifically, an itemized bill showing how much was paid for the influenza vaccine was not submitted. This 
means the Plan cannot determine how much to reimburse for the service. Therefore, we decided that the Plan 
does not have to pay for an influenza vaccine provided on October 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on April 06, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that this copayment is too high, and the 
hospital was only 2 miles from the skilled nursing facility. The Plan denied your request. The Plan says the cost 
sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment per one-way trip for Medicare-covered ambulance services. Covered ambulance services include 
fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide 
care if they are furnished to a member whose medical condition is such that other means of transportation could 
endanger the persons health or if authorized by the plan. 
 
 
 
 You have been asked to pay a $225 copayment for ambulance. Ambulance falls within the Ambulance 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 ambulance on April 06, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 4, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support this level of service. You say that the claim should be reconsidered 
for processing. 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 November 4, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic device and pneumatic device supplies to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic device and pneumatic device supplies. You say that another 
supplier will not be able to provide the same prescribed program the physician has ordered from this brand of 
device. You also say that in-network pneumatic compression device treatment programs will not correlate nor 
be equivalent to the prescribed plan of care from this device and cannot provide the same therapeutic action 
ordered. The Plan denied your request. The Plan says the requested provider is out-of-network for the member's 
insurance. The network provider of the requested provider has confirmed they can provide the requested items 
with a different brand than the out-of-network 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic device and pneumatic device supplies to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiographic survey of the whole mouth (D0210) provided 
on April 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you call the dentist office and asked if they were 
in the Plan network, and they said yes. You also say that the day of the appointment, you asked if they were in 
the Plan network, and they said yes. You also say that they also told you that the Plan would pay off of the 
exam expenses, so you agreed to do the exam. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 8, 2019. 
Therefore, we decided that the Plan does not have to pay for a radiographic survey of the whole mouth (D0210) 
provided on April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiography service provided on 
April 14, 2022. 
 
You asked the Plan to waive the copayment for an echocardiography service. You say that you cannot 
understand why this copayment is so high and feel it should be lowered. The Plan denied your request. The 
Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for diagnostic radiology services.  
 
You have been asked to pay a $125 copayment for an echocardiography service. An echocardiography service 
falls within the Diagnostic Radiology 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 an echocardiography service provided on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the office visit provided on April 7, 2022. 
 
You asked the Plan to reduce the copayment for the office visit. You say that your primary care physician was 
unavailable on the date of service, so you had to see the nurse practitioner instead. 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 $45 
copayment for a specialist visit.  
 
You have been asked to pay a $45 copayment for a specialist visit. The 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 reduce the copayment for the office visit provided on April 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service October 28, 
2021. 
 
You asked the Plan to pay for procedure code 71045. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 71045 is bundled into 
payment for code 36580. 
 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 71045 
is a column II code to column I code 36580. 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 71045 billed for date of service October 28, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan of the lower 
jawbone (D0365) provided by an out-of-network provider on January 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were informed the providers office does 
not accept insurance claims after the provider mistakenly received a check from the Plan. You say the Plan 
claims to have corrected the error, but you are still owed $322. You say you have not received payment.   The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. The Plan says the claim has 
been reprocessed and you have been reimbursed for the correct amount. Furthermore, the Plan says cone beam 
CT scans are not covered under your dental package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
record shows that a check in the amount of $322 was sent to you on June 6, 2022. Therefore, we decided that 
the Plan does not have to pay more for a problem-focused oral exam (D0140) and endodontic therapy of a 
molar tooth (D3330). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the cone beam CT scan is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone beam 
computed tomography (CT) scan of the lower jawbone (D0365) provided by an out-of-network provider on 
January 19, 2022.