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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 enrollee appears to be improving but is still not yet stable enough for transfer and 
should only require short-term additional acute care services that can be safely administered 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 a lower level of care may be considered when treatment is completed 
and the enrollee is more stable with feeding status. 
 
 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92004), provided on August 23, 2021. 
 
You asked the Plan to pay for the eye exam. You say that the services should be covered. The Plan denied your 
request. The Plan says the services were obtained out-of-network with no prior authorization. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when obtained through a Plan provider. 
 
We looked at the file and the Plan's rules. These services were obtained through an out-of-network provider 
without prior authorization. Based on this information, we decided that the Plan's rules for coverage of the eye 
exam have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam (92004), 
provided on August 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from November 28, 2020 to December 13, 2020. 
 
You asked the Plan to waive the copayment for SNF care. You say that the services should be covered as you 
were under the impression that the first 21 days were covered. The Plan denied your request. The Plan says the 
cost-sharing applied correctly based on the services provided. since  
 
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 $178 
copayment per day for days 21-100 of Skilled nursing facility (SNF) care.  
 
 
  You have been asked to pay a $2,492 copayment for days 21-35 of SNF care ($178 x 14 = $2,492). Because it 
had been less than 60 days since your previous SNF stay, your second stay is considered the same benefit 
period and is subject to the $178 per day copayment. 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 
skilled nursing facility (SNF) care provided from November 28, 2020 to December 13, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for abdominal (76705) and retroperitoneal (76770) ultrasounds 
provided on November 2, 2021. 
 You asked the Plan to pay for abdominal and retroperitoneal ultrasounds. You say that you have provided 
records to support the level of service. The Plan denied your request. The Plan says rules for payment have not 
been met because the services at issue are inclusive to another billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
76705 and 76770 are column II codes to column I code 93976. This claim has not been billed with appropriate 
modifiers to bypass the edits. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for abdominal (76705) and retroperitoneal (76770) 
ultrasounds provided on November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatments provided on November 
10, 2021, to December 6, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic manipulative treatments. You say that you did not realize your 
authorization had expired. You would like the services covered as in-network as they have seen covered in the 
past. The Plan denied your request. The Plan says no prior authorization was obtained for these dates of 
service. 
 
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 chiropractic manipulative treatments provided on 
November 10, 2021, to December 6, 2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services rendered on October 6, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until December 8, 2021. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the emergency room services rendered on October 6, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
October 15, 2021. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for Emergency care.  
 
You have been asked to pay a $120 copayment for an emergency room visit. Based on your contract with the 
Plan, cost-sharing for emergency care is only waived if you are admitted into the hospital within 24 hours of 
the same condition. 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 visit 
provided on October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
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 these 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 the laboratory services rendered on August 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services (A0427, A0425) 
provided on November 8, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the ICD-10 codes for these services are 
R57.9 and Z74.3, and these services were medically necessary. The Plan denied your request. The Plan says 
this claim was submitted with a secondary-only diagnosis code listed as the primary diagnosis. This claim was 
not billed according to Medicare regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules state that secondary only diagnosis codes cannot be used as the primary, first-listed or principal 
diagnosis for any procedure or service. 
 
We looked at the file and Medicare rules. This claim was submitted with secondary-only diagnosis code 
T36.8X5A listed as the primary diagnosis. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Corrected claims may be submitted to the Plan directly. 
Therefore, we decided that the Plan does not have to pay for the ambulance transportation services (A0427, 
A0425) provided on November 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the knee brace (knee orthosis) (L1851) and sleeve (L2397), 
provided on November 4, 2021. 
 
You asked the Plan to pay for the knee brace and sleeve. You say that the items were medically necessary. The 
Plan denied your request. The Plan says the records show you have not had a recent injury or surgery to your 
knee and the notes do not show that your knee is unstable on exam. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for the requested item to be covered, you 
would need to have: a recent injury to or surgery on the knee; or, the ability to walk and an exam that shows 
your knee is unstable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the knee brace and sleeve have not been met. Therefore, we decided that the Plan does not have to 
pay for the knee brace (knee orthosis) (L1851) and sleeve (L2397), provided on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, trifocal lens, and anti-reflective lens coating 
(V2303, V2750, V2020), provided on October 29, 2021. 
 
You asked the Plan to pay for the eyewear. You say that the items should be covered. The Plan denied your 
request. The Plan says you have exceeded the Plan's maximum allowance and are responsible for the 
difference. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when eyewear with a $150 allowance per a year. If your purchase 
costs are more than the allowance, you pay the difference. 
 
We looked at the file and the Plan's rules. You exceeded the Plan's maximum allowance for this benefit and are 
responsible for the difference. Based on this information, we decided that the Plan's rules for coverage of the 
eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the frames, trifocal 
lens, and anti-reflective lens coating (V2303, V2750, V2020), provided on October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered in full as the office visit was unnecessary and uneventful. The Plan denied your request. The Plan says 
the cost-sharing applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 
  You have been asked to pay a $45 copayment for the specialist office visit. Specialist office visits fall 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 for a specialist office visit
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 enrollee appears to be improving and more stable and should only require short-
term additional acute care services that can be safely administered 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 a lower level of care may be considered when treatment is completed and the patient is more stable. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015), provided on November 15, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that the service should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one routine eye exam a year. 
 
We looked at the file and the Plan's rules. You did not receive a routine eye exam. Based on this information, 
we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided 
that the Plan does not have to pay for the eye refraction (92015), provided on November 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gastric emptying imaging study (78264) provided October 
28, 2021 
 
You asked the Plan to pay for the imaging services. You say that the procedure was rendered in appropriate 
place of service. Please review and reconsider claim for payment. The Plan denied your request. The Plan says 
the claim was billed with an inappropriate place of service. 
 
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, the CPT Code Manual definition of code 78264 is gastric emptying imaging study (eg, solid, 
liquid, or both).  
We find that CPT code 78264 is not supported in the medical record. Specifically, the claims history shows that 
the enrollee was inpatient during this date of service. The clam was billed with place of service 22 (outpatient 
hospital). Of note, the medical records received only contain the interpretation with no indication that the 
enrollee was inpatient or outpatient. Based on this information, we decided that Medicare rules for coverage of 
the imaging services have not been met. Therefore, we decided that the Plan does not have to pay for gastric 
emptying imaging study (78264) provided October 28, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the eye exam (92012), provided on October 27, 2021. 
 You asked the Plan to pre-approve the eye exam. You say that the service should be covered. The Plan denied 
your request. The Plan says prior authorization must be obtained for out-of-network services. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when network providers are used. 
 
We looked at the file and the Plan's rules. You must use a participating network provider for vision care. Based 
on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the eye exam (92012), provided on October 
27, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound rendered on November 9, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 76705 (abdominal ultrasound) and 93976 (vascular study). 
Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 
76705 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that 
the Plan does not have to pay for the abdominal ultrasound rendered on November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an elbow cast application performed on 
October 27, 2021. 
 
You asked the Plan to waive the copayment for the cast application. You say that the cast was covered but the 
application was not. 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 $100 
copayment for surgery or other services at an outpatient hospital facility or ambulatory surgical center.  
 
You have been asked to pay a $100 copayment for the cast application. Please note that the application is covered, but the copayment still applies for the procedure. The cast application 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 an elbow cast application performed on 
October 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 20, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 20, 
2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for triamcinolone acetonide (Kenalog, a Medicare Part B 
prescription drug with code J3301) provided on December 1, 2021. 
 
You asked the Plan to pay for Kenalog. You say that you are requesting full payment of the $24 that you paid 
for this drug. The Plan denied your request. The Plan says the denial of additional reimbursement is correct, 
because you were reimbursed $1.20 which is the payment limit for drug code J3301. 
 
The Plan must follow Medicare rules. Medicare rules say that the payment allowance limit for Kenalog (J3301) 
is $1.199 per unit.  
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The Plan reimbursed you $1.20, which is the payment limit for this 
drug rounded up to the nearest whole cent. Therefore, you have been reimbursed the appropriate amount under 
Medicare rules. Based on this information, we decided that Medicare rules for additional reimbursement for 
Kenalog have not been met. Therefore, we decided that the Plan does not have to pay for triamcinolone 
acetonide (Kenalog, a Medicare Part B prescription drug with code J3301) provided on December 1, 2021.