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

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
April 20, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that the colonoscopy was 
for a preventative screening, and you should not be responsible to pay this. The Plan denied your request. The 
Plan says this cost sharing was charged 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 a $200 
copayment for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility.  
 
You have been asked to pay a $200 copayment for a diagnostic colonoscopy.  This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
diagnostic colonoscopy provided on April 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an intravitreal injection of Bevacizumab 
provided on May 11, 2022. 
 
You asked the Plan to waive the copayment for an intravitreal injection of Bevacizumab. The Plan denied your 
request. The Plan says this cost sharing was charged 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 a $350 
copayment for outpatient hospital services.  
 
You have been asked to pay a $350 copayment for an intravitreal injection of Bevacizumab. This service falls 
within the outpatient hospital services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an intravitreal injection of Bevacizumab provided on May 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation 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 a genicular nerve 
radiofrequency ablation in the setting of osteoarthritis of the knee have 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. The role of genicular 
radiofrequency ablation is still being investigated. It is considered an experimental procedure at this point. 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 genicular nerve radiofrequency ablation for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit and nail debridement provided 
on May 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary or rest home visit and nail debridement. 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 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 domiciliary or rest home visit and nail 
debridement provided on May 18, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for set up of portable x-ray equipment (code Q0092) provided 
on July 23, 2021. 
 
You asked the Plan to pay for set up of portable x-ray equipment. The Plan denied your request. The Plan says 
the billed code is not payable in connection with EKG services. 
 
The Plan must follow Medicare rules. Medicare rules say that A/B MACs (B) do not make the set-up payment 
for EKG services furnished by the portable x-ray supplier.  
 
We looked at the file and Medicare rules. Medicare does not pay for set-up payment for EKG services 
furnished by the portable x-ray supplier. Therefore, we decided that the Plan does not have to pay for set up of 
portable x-ray equipment (code Q0092) provided on July 23, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for hospital observation services provided from March 14, 2022, to March 
17, 2022. 
 
You asked the Plan to pay for the hospital observation services. You say that you were not aware that the 
provider had billed for observation. The Plan denied your request. The Plan says that the provider billed over 
the maximum 48-hour observation hours by submitting 70 hours. 
 
In this case, the Plans sole basis for denial is that the provider billed more than 48 hours of observation and the 
Plan claims this is not allowed.  This is not true.  Medicare rules explicitly state that while observation services 
usually span less than 48 hours, however, in rare and exceptional cases, additional hours are permitted. The 
Plan has not even attempted to get any medical records from this hospital stay to determine if such rare and 
exceptional circumstances existed in this case.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Because the Plan failed to even try to get records, it would be impossible for the 
Plan to have adequately reviewed them to determine if your scenario met the rare and unusual exception to 
the 48-hour typical span for observation services. The burden is on the Plan to show why its denial is 
appropriate.  By failing to provide and review these records, the Plan has not met this burden. Therefore, we 
decided that the Plan has to pay for hospital observation services provided from March 14, 2022, to March 17, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 23, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment based on the medical records. The Plan denied your request. The Plan says prior 
authorization was not obtained for these services rendered and referred by 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 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 23, 
2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on March 11, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says services provided out-of-network, without prior authorization, are not 
covered. 
 
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 outpatient services provided on March 11, 2022, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that enrollee needs more diligent therapy to 
get weaned off respirator. The Plan denied your request. The Plan says this is not medically necessary, and care 
can be met in current setting. 
 
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 transfer to the LTACH is not medically necessary at this time 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a DTRAX spinal system facet joint spacer. 
 
You asked the Plan to pre-approve a DTRAX spinal system facet joint spacer. You say that you are in constant 
pain and need to regain your maximum functionality. The Plan denied your request. The Plan says the 
requested procedure has not been shown to be safe and effective in long term studies. The Plan says that there 
is a lack of evidence to support that facet spacer devices are as safe and effective as the gold standard of 
decompression or fusion. 
 
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 a DTRAX spinal system facet joint 
spacer. Our reviewer says that a DTRAX spinal system facet joint spacer is not considered medically 
reasonable and necessary in this case. Our physician reviewer found the DTRAX spacer is experimental, and 
more research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a DTRAX spinal system facet joint spacer have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a DTRAX spinal system facet joint spacer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that enrollee is too complex for SNF and 
poses significant risk for another re-admission. The Plan denied your request. The Plan says this is not 
medically necessary, and care can be provided at a lower level of care. 
 
 
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 the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 
 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be optimally restored 
at any other level of care, due to their complex respiratory needs and high level of oxygen. Among many 
reasons, there is a high degree of likelihood they will require readmission back to a short term-acute care 
hospital again if not placed appropriately. The Plan denied your request. The Plan says this is not medically 
necessary and can safely receive care in the hospital setting. 
 
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 transfer to the LTACH is not medically necessary at this time as the patient is too 
unstable for transfer right now 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 LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on March 16, 
2022. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you already paid this 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $40 for 
outpatient rehabilitation services.  
 
 
 
 
 
 You have been asked to pay $35.08 for physical therapy, which is lower than the standard $40 copayment 
amount. This item/service 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 copayment for physical therapy provided on March 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on January 2, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that your spouse called an ambulance because 
you were unconscious on the floor. You say that your spouse thought you had had a stroke. You say that by the 
time the ambulance arrived, you were conscious. You also say that you though if you went to the hospital, it 
would cost you and the plan more money. The Plan denied your request. The Plan says since there was no 
transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 2, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on January 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on June 13, 2022. 
 
You asked the Plan to pay for eyeglasses. You say that this provider provides excellent eyeglasses at a much 
better price point with outstanding service. The Plan denied your request. The Plan says while you are a 
member of the Plan, you must use network providers to get your vision care and services. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services when you see a network vision provider. 
 
We looked at the file and the Plan's rules. The eyeglasses were not provided by a network vision provider. 
Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. 
Therefore, we decided that the Plan does not have to pay for eyeglasses provided on June 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc (J7325). 
 
You asked the Plan to pre-approve Synvisc. You say that the requested injection is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Synvisc (J7325).  
 
Benefits for Synvisc 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided 
on March 26, 2022. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99233 is not supported in the medical record. Specifically, this service is included in the 
payment made. According to the AMA CPT Professional Edition Anesthesia Guidelines: Payment may not be 
made for services 
included in the anesthesia care package when furnished by the same provider or the same provider specialty 
within a group 
practice. Anesthesia care packages consist of pre-op evaluation, standard operation, and monitoring services, 
administration of anesthesia and post-op anesthesia recovery care. This query identifies patients who have had 
E/M services billed on the day of, the day before and/or during the post-op period for an anesthesia procedure. 
Both of the billing providers have the same tax identification number. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we 
decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided on 
March 26, 2022.