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

 
We decided that the Plan does not have to pay for drug testing services provided on June 27, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing services. You say that you have attached the lab report to support 
this service. The Plan denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care 
have not been met."] 
 
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. 
 Neither the lab nor the referring provider in this case is 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 drug testing services provided on 
June 27, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
April 25, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you were not informed about this additional cost, 
and it is a hardship. The Plan denied your request. The Plan says this service is only covered when provided as 
part of a routine exam.  
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 provided during a routine eye exam. 
 
We looked at the file and the Plan's rules. The records show that this eye refraction was performed as part of a 
medical 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 determination of refractive 
state (92015) provided on April 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on May 11, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. 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 $225 
copayment per one-way trip for Medicare-covered ambulance services. Covered ambulance services include 
fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide 
care if they are furnished to a member whose medical condition is such that other means of transportation could 
endanger the persons health or if authorized by the plan. 
 
You have been asked to pay a $225 copayment for ambulance. This item/service falls within the Ambulance 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance on May 11, 
2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for 75825. We decided that the Plan does not have to pay for 75822.  
 
You asked the Plan to pay for venography services (procedure codes 75822 and 75825) provided to the enrollee 
on July 18, 2022.. You say that this should be paid for. The Plan says that the denied codes cannot be verified. 
 
We decided that the Plan has to pay for 75825.  
 
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 
CPT 75825 is "Venography, caval, inferior, with serialography, radiological supervision and interpretation." 
 
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 75825. Our reviewer says that  Our physician reviewer found that diagnostic venography is separately reportable from venous stenting unless there was a 
recent diagnostic venogram. In this case, there is satisfactory documentation of a diagnostic intraventricular 
venogram that includes the iliac veins. Therefore, coverage of code 75825 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 services have been met. Therefore, we decided that the Plan has to pay for 
75825.  
 
We also decided that the Plan does not have to pay for 75822. 
 
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 
CPT 75822 is "Venography, extremity, bilateral, radiological supervision and interpretation." 
 
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 75822. Our reviewer says that there is no 
description of a venogram in either lower extremity. This code is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 75822 have not been met. Therefore, we decided that the Plan does not have to 
pay for 75822. 
 
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 pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that prior to hospitalization the enrollee was very 
independent, IRF care would better assist their recovery. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF admission and services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued SNF services after October 26, 2022. 
 
You asked the Plan to pre-approve continued SNF care. The Plan denied your request. The Plan says that 
continued skilled nursing facility services are not medically necessary. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before October 26, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pre-approve continued SNF services after October 26, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Pronex device, cervical traction equipment (E0855). 
 
You asked the Plan to pre-approve the Pronex device. You say that the device is medically necessary due to 
other general symptoms and signs. The Plan denied your request. The Plan says the clinical does indicate that 
this home cervical traction device has been demonstrated to the beneficiary and beneficiary tolerate the selected 
device. 
 
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 Pronex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at issue is whether Pronex pneumatic cervical traction device. for the enrollee is a 
covered service under Medicare rules.  The local coverage determination enumerates the conditions and 
limitations of coverage of the requested service. In this case, the record indicates that the enrollee has cervical 
degenerative disc disease.  The record provided does not document that the enrollee a has musculoskeletal or 
neurologic impairment requiring traction equipment.  The elements of the coverage criteria are not satisfied.  
The requested service is not 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 Pronex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Pronex device, cervical traction equipment (E0855).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from June 1, 2022, to 
June 17, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were told your SNF stay would 
be covered until June 16, 2022. 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 your out-of-pocket 
maximum for in-network and out-of-network covered services is $7,550. Your contract with the Plan also 
clearly says that you pay $0 per day, for days 1 to 20; $188 per day for days 21 to 100 for each SNF stay. The 
Plan contract also says a benefit period begins the day you go into a hospital or skilled nursing facility. The 
benefit period ends when you havent received any inpatient hospital care (or skilled care in a SNF) for 60 days 
in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit 
period begins. There is no limit to the number of benefit periods you can have.  
 
The records show you were admitted to a SNF from April 1, 2022, to April 15, 2022, for a total of 14 days. The 
records also show you were admitted to a SNF from May 24, 2022, to May 30, 2022, for a total of 6 days. You 
have been asked to pay a total of $2,620 for a SNF stay, which is less than a $188 copayment per day because 
your out-of-pocket maximum was met during the processing of this claim. 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 SNF stay provided from June 1, 2022, to June 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20936 billed for date of service June 1, 2022. 
 You asked the Plan to pay for procedure code 20936. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 20936 is considered bundled 
and 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 procedure code. 
 
We find that procedure code 20936 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20936 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20936 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20936 billed for date of service June 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that without IRF services you will not get better. Skilled 
nursing services repeatedly resulted in re-hospitalizations. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair prosthetic device services provided from May 16, 
2022, to May 18, 2022. 
 
You asked the Plan to pay for the repair prosthetic device services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the documentation does not support the time spent. 
 
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 L7520 is repair prosthetic device, labor component, per 
15 minutes. 
 
 
 We find that CPT code L7520 is not supported in the medical record. Specifically, the documentation does not 
include the time spent for the prosthetic repair time. Based on this information, we decided that Medicare rules 
for coverage of the repair prosthetic device services have not been met. Therefore, we decided that the Plan 
does not have to pay for the repair prosthetic device services provided from May 16, 2022, to May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G. 
 
You asked the Plan to pre-approve the MyoPro Motion G. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item is 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 the MyoPro Motion G. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records do not clarify why the requested device is the most appropriate treatment for the 
enrollee's condition. In addition, provided records report left upper extremity spasticity and left shoulder 
subluxation which may be a contraindications to use of the device. 
 
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 MyoPro Motion G have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the MyoPro Motion G.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 20, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 June 20, 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 office visit (99213) and urinary test (51798), provided on 
June 7, 2022. 
 
You asked the Plan to pay for the office visit and urinary test.. You say that the service should be covered. 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 $35 
specialist copayment for Physician/Practitioner services, including doctors office visits.  
 
You have been asked to pay a $35 specialist copayment for the office visit and urinary test. This service falls 
within the Physician/Practitioner services, including doctors office visits benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to pay for the office visit (99213) and urinary test (51798), provided on June 7, 2022.
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 LTACH level of care is appropriate for 
the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) scan, thorax, low dose for lung 
cancer screening, without contrast material(s) provided on March 18, 2022. 
 
You asked the Plan to pay for the CT scan. You say that the service was medically necessary. The Plan denied 
your request. The Plan says with the information we have, we cannot determine how the member came to the 
servicing provider, or whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the CT scan have been met. Therefore, 
we decided that the Plan does not have to pay for computed tomography (CT) scan, thorax, low dose for lung 
cancer screening, without contrast material(s) provided on March 18, 2022.