Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 office visit provided on January 20, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology for tongue lesion provided on June 17, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for surgical pathology for tongue lesion. You say that you were sent to this surgeon 
by your dentist, not a prime care provider. They were not involved at all. The Plan denied your request. The 
Plan says there was no preauthorization for an OON provider or facility, and this was not an emergency. 
Therefore, the payment is correct. 
 
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 surgical pathology for tongue lesion provided on 
June 17, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous laminotomy/laminectomy (CPT code 
0275T) and laminotomy (hemilaminectomy) (63030). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found percutaneous laminectomy remans experimental. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the percutaneous laminotomy/laminectomy (CPT code 0275T) and laminotomy 
(hemilaminectomy) (63030).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued acute inpatient hospital level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the denial of authorization for continued 
inpatient level of care is correct. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient level of care are met. Our 
physician reviewer found the enrollee was admitted to the hospital, diagnosed with dementia, and needed long-
term placement. The enrollee's vitals were stable and overall workup was negative. There is no indication that 
the enrollee would require continued inpatient level of care beyond the Plan's proposed discharge date. 
 
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 pre-approve continued acute inpatient hospital level of care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic test provided on June 
6, 2022. 
 
You asked the Plan to waive the copayment for echo exam of the head and neck. You say that they have had 
the same service and not had to pay a $100 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 $100 
copayment for Medicare-covered ultrasound.  
 
You have been asked to pay $100 copayment for echo exam of the head and neck. This item/service falls 
within the Medicare-covered ultrasound 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 outpatient diagnostic test provided on June 6, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided February 21, 2022, and May 25, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you were not aware these services would not be 
covered. The Plan denied your request. The Plan says that these services were not authorized. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for laboratory services by a contract provider. The file does not show that the Plan provided 
notice that these laboratory services would not be covered. Under Medicare rules, this means these laboratory 
services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for laboratory 
services provided February 21, 2022, and May 25, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone/joint study provided on June 17, 2022. 
 
You asked the Plan to pay for a bone/joint study. You say that the enrollee recently changed their Medicare 
plan and was not informed of the change. The Plan denied your request. The Plan says the enrollee must 
receive care from a 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 pay for a bone/joint study 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 a bone/joint study these 
items/services. Therefore, we decided that the Plan does not have to pay for a bone/joint study provided on 
June 17, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurology services provided to the enrollee on April 13, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation does not support service billed. 
 
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 the denied codes is: 
 
Current Procedural Terminology (CPT) 95886 Needle electromyography, each extremity, with related 
paraspinal areas, when performed; complete, five or more muscles studied, innervated by three or more nerves 
or four or more spinal levels (List separately in addition to the primary procedure) 
 
Current Procedural Terminology (CPT) 95908 Nerve conduction studies; 3-4 studies 
 
Current Procedural Terminology (CPT) 95937 Neuromuscular junction testing (repetitive stimulation, paired 
stimuli) each nerve, any 1 method 
 
Current Procedural Terminology (CPT) 95955 Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 95886, nerve 
conduction studies cannot be verified, and therefore this procedure would not be covered. In terms of CPT 
95908, the operative report documents "Pedicle screws were tested to help determine appropriate placement". 
Therefore, this procedure cannot be verified. In terms of CPT 95955, that the procedure report does not include 
documentation of additional EEG testing, and therefore this procedure cannot be verified. In terms of CPT 
95937, the procedure report describes train of four (TOF) monitoring, which would not be reported with 
neuromuscular junction testing. TOF testing is inclusive to the primary neuromonitoring procedure, and there is 
no CPT code for TOF testing. 
 
We looked at this coder'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 neurology services provided to the enrollee on April 13, 2022.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 36227. We decided that the Plan does not have to pay for 36222, 
36217, and 36218.  
 
You asked the Plan to pay for neurology services provided to the enrollee on March 23, 2022.. You say that 
this should be paid for. The Plan says that the code criteria has not been met. 
 
We decided that the Plan has to pay for 36227.  
 
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 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 for CPT 36227.  Our reviewer says that the procedure report documents selective catheter placement, external carotid artery, and 
the guidelines, this procedure would be reported in addition to CPT 36222, 36223, and 36224. Additionally, in 
this case, CPT 36222 would not be reported in addition to CPT 36223, as in this group of codes, CPT 36223 is 
the most comprehensive and includes CPT 36222. In terms of CPT 36217, is inherent to selective 
catheterization of carotid circulation codes CPT 36222 - 36227. Therefore, this procedure cannot be verified. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
36227.  
 
We also decided that the Plan does not have to pay for 36222, 36217, and 36218. 
 
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 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 for the rest of the codes. Our reviewer says that per the 
guidelines, CPT 36218 is inherent to selective catheterization of carotid circulation codes CPT 36222 - 
36227. Therefore this procedure cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 36222, 36217, and 36218 have not been met. Therefore, we decided that the 
Plan does not have to pay for 36222, 36217, and 36218. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider on 
March 23, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you were told the provider would submit the claim 
and you would pay the difference between the paid amount and billed amount. The Plan denied your request. 
The Plan says the provider was not a part of the vendor network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only hearing aids purchased outside of the Plan's Hearing network are not covered.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the provider was out-of-network. Therefore, we 
decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider on 
March 23, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an inpatient hospital stay provided on February 7, 2022, by an out-of-
network facility. 
 
You asked the Plan to pay for an inpatient hospital stay. You say that you do not agree with the decision and 
would like the Plan to reprocess the denied claim for services provided on February 7, 2022. The Plan denied 
your request. The Plan says that you must receive your care from a network provider. 
 
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. The Plan did not submit the correct Evidence of Coverage. This means that we 
cannot determine the cost you are being asked to pay is correct or justified by the Plan contract. Therefore, we 
decided that the Plan has to pay for an inpatient hospital stay provided on February 7, 2022, by an out-of-
network facility.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 26, 
2022, to May 30, 2022. 
 
You asked the Plan to waive the copayment for hospital care. You say that you are disputing the quality of care 
which they believe led to the emergency room visit. 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 $295 
copayment per day for days 1 to 5 for Medicare-covered hospital care. This inpatient hospital stay lasted 4 
days, resulting a copayment of $1,180 ($295 per day for 4 days = $1,180). 
 
You have been asked to pay $295 copayment per day for days 1 to 5 for hospital care. This item/service falls 
within the Medicare-covered hospital 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 inpatient hospital care provided on May 26, 2022, to May 30, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting SNF services. The Plan denied 
your request. The Plan says this is not medically necessary and does not meet the criteria for SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
March 25, 2022, to April 1, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you believe the 
copayment is too high. 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 per day for days 1-5 and $0 after day 5 for inpatient hospital care.  
 
You have been asked to pay for four days of your inpatient hospital stay, for a total of $1,400 ($350 x 4). This 
item/service falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an inpatient hospital stay provided from March 25, 2022, to April 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic eye imaging provided on July 8, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic eye imaging. You say that the services were medically necessary. 
The Plan denied your request. The Plan says authorization was not obtained prior to services being rendered. 
 
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 diagnostic eye imaging provided on July 8, 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need help with ambulation. The Plan denied 
your request. The Plan says you do not require regular nursing and physician oversight. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for sepsis. Your medical problems are stable. The complexity of 
your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. 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.