Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) provided 
on April 16, 2022. 
 
You asked the Plan to waive the copayment for the outpatient office visit. You say that you were under the 
impression there would be no charge for this eye exam because it was an annual exam The Plan denied your 
request. The Plan says the copayment amount 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 $10 
copay for outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, 
including treatment for age-related macular degeneration under the Vision care.  
 
 
  The record shows you received an eye exam related to a medical condition. You have been asked to pay a $10 
copay for the outpatient office visit. The outpatient office visit falls within the outpatient physician services for 
the diagnosis and treatment of diseases and injuries of the eye under the Vision 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 the outpatient office visit (99213) provided on April 16, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from October 15, 2020, through 
October 19, 2020, at DRG 551. 
 
You asked the Plan to pay for inpatient services at DRG 551. You say that secondary diagnosis code G93.41 is 
supported and DRG 551 is correct. You say that you should be reimbursed for the services rendered at DRG 
551. The Plan denied your request. The Plan says secondary diagnosis code G93.41 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with secondary diagnosis code G93.41, defined as metabolic 
encephalopathy. 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 inpatient services at DRG 
551. Our reviewer says that the documentation does not support secondary diagnosis code G93.41. Our 
physician reviewer found that a diagnosis of metabolic encephalopathy was stated to be possible at discharge, 
but the remainder of the record did not include clinical support to validate this diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from October 15, 2020, through October 19, 2020, at DRG 551.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of LTACH 
admission. The Plan denied your request. The Plan says the requested services were denied as not meeting 
criteria, is not medically necessary, and continued acute hospital stay was offered until the enrollee could 
discharge to 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 enrollee was admitted to the acute care hospital with ischemic bowel, lactic 
acidosis requiring laparotomy, lysis of adhesions, colectomy, ileostomy, intra-abdominal abscess drain 
placement, and IV antibiotics. The course was complicated by acute kidney injury. Recent notes describe the 
enrollee with stable vitals and tolerating full liquid diet, but will requiring some tube feedings, JP and IR drain 
care, urostomy care, and ongoing intravenous antibiotics. Palliative care was consulted.   
 The enrollee appears to be improving but is still somewhat unstable (needs more stable feeding source) and 
should only require additional acute care services that can safely be administered at the current facility until 
more stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that 
are not available at the current facility where they are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on April 12, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for a drug test. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
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 a drug test provided on April 12, 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 telephone evaluation and management service provided on 
May 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for telephone evaluation and management service. You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for telephone evaluation and management service 
provided on May 3, 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 office visit provided on February 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the referral was not requested until after the 
appointment. You say that the referral has now been sent to provider. 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 office visit provided on February 23, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment delivery. 
 
You asked the Plan to pre-approve proton treatment delivery. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve proton treatment delivery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a systematic review of the available evidence from American Society for Radiation 
Oncology (ASTRO) on efficacy and toxicity concluded that outcomes were similar with proton beam therapy 
and intensity-modulated radiation therapy (IMRT) using photons but did not demonstrate a benefit for the 
proton beam approach. The National Comprehensive Cancer Network (NCCN) Panel believes no clear 
evidence supports a benefit or decrement to proton therapy over Intensity-modulated radiation therapy (IMRT) 
for either treatment efficacy or long-term toxicity. Conventionally fractionated prostate proton therapy can be 
considered a reasonable alternative to x-raybased regimens at clinics with appropriate technology, physics, 
and clinical expertise. The ASTRO evaluated proton therapy and created a model policy to support the societys position on payment coverage for proton beam therapy in 2017 and recommends coverage of proton 
therapy for the treatment of non-metastatic prostate cancer if the patient is enrolled in either an institutional 
review board (IRB)-approved study or a multi-institutional registry that adheres to Medicare requirements for 
Coverage with Evidence Development (CED). There is no documentation that the enrollee will be on a study or 
part of a registry. Therefore, the enrollee does not meet criteria for the requested 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 proton treatment delivery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve proton treatment delivery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services provided on April 4, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical pathology services. You say that the enrollee does not go to your 
laboratory so they are not using out-of-network benefits because their participating provider sends the 
specimen. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
 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 
surgical pathology services. We found no exception that would require the Plan to pay for the surgical 
pathology services. The records provided for review do not show that the surgical pathology services were 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for the surgical pathology 
services provided on April 4, 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 the determination of refractive state (92015) provided on 
January 25, 2022. 
 
You asked the Plan to pay for the vision care. You say that this should be paid. The Plan denied your request. 
The Plan says the claim processed correctly. 
 
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 billed as part of the routine eye exam. 
 
We looked at the file and the Plan's rules. Refraction is only covered when billed as part of the routine eye 
exam. Based on this information, we decided that the Plan's rules for coverage of the vision care have not been 
met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) 
provided on January 25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on July 15, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for domiciliary services provided on July 15, 2021, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle-foot orthosis and foot stabilizer provided on April 
8, 2022. 
 
You asked the Plan to pay for the ankle-foot orthosis and foot stabilizer. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the documentation is missing required information. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the enrollee received these items in the mail after receiving a phone 
call about receiving equipment from Medicare. The enrollee also told the caller that they did not need any of 
these items. The enrollee does not use the items received. The medical records do not support the need for the items rendered. This means these items were provided in a prohibited telemarketing contact. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the ankle-foot orthosis and foot stabilizer provided on April 8, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for services provided on September 29, 
2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation is insufficient to corroborate the services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that CPT codes 87481, 87640, 87653, 87798, and 87801 are not supported in the medical record. The 
documentation provided do not include test results for the billed codes. The documentation does not show the 
treating physicians intent for the tests to be performed. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
testing billed for services provided on September 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a uvulopalatopharyngoplasty procedure. 
 
You asked the Plan to pre-approve the requested services. You say that you have sleep apnea that needs to be 
treated. The Plan denied your request. The Plan says you do not meet the coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that surgical treatment for obstructive sleep apnea is only 
covered under certain medical indications. 
 
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 requested services. Our physician 
reviewer found that you were assessed to have severe snoring with mild obstructive sleep apnea by history. A respiratory diagnostic testing documents no evidence of obstructive sleep apnea during this study, mild sleep 
related hypoxemia, and mild snoring. You have not had obstructive sleep apnea diagnosed (prior to any 
proposed surgery) in a certified sleep disorders laboratory, or a respiratory disturbance index of 15 or higher. 
Therefore, the requested services are not medically reasonable or necessary at this time. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a uvulopalatopharyngoplasty procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a knee procedure provided on November 8, 
2021. 
 
You asked the Plan to waive the deductible for a knee procedure. You say that you have no control over which 
participating and non-participating providers are present during a procedure. Therefore, you should not have to 
pay this out-of-network deductible. The Plan denied your request. The Plan says the deductible applied was 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to understanding your out-of-pocket 
costs for covered services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Understanding Your Out-Of-Pocket Costs for Covered Services. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $500 deductible which applies to understanding your out-of-
pocket costs for covered services. You have been asked to pay $171.38 for this procedure. This cost sharing is 
a contractual obligation that had not been met at the time a knee procedure was received on November 8, 2021. 
Therefore, we decided that the Plan does not have to waive the deductible for a knee procedure provided on 
November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye appointment provided on April 18, 
2022. 
 
You asked the Plan to waive the copayment for an eye appointment. You say that you should not have to pay 
this copayment. 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 $40 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
You have been asked to pay a $40 copayment for an eye appointment. an eye appointment falls within the 
Physician/Practitioner services, including doctor's 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 an eye appointment provided on April 18, 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 February 9, 
2022. 
  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 the 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 February 9, 
2022.