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

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from November 5, 2021, to November 30, 2021. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that the providers service was bad. The 
Plan denied your request. The Plan says the proper copayment was applied. 
 
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 $0 
copayment per day, days 1 to 20 and a $125 copayment per day, days 21 to 40 for a Skilled Nursing Facility. 
From November 5, 2021, to November 30, 2021, there was a total of 26 days. The copayment for the first 20 
days is $0. The total copayment amount for the last 6 days was $750 ($125 copayment per day x 6 days). 
 You have been asked to pay a $750 copayment for the SNF stay. The SNF stay falls within the Skilled nursing 
facility (SNF) 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 a skilled nursing 
facility (SNF) stay provided from November 5, 2021, to November 30, 2021.  
 
Your complaint about your experience with this provider is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on November 17, 2021, and 
November 23, 2021, by an OON provider. 
 
You asked the Plan to pay for the physician services. You say that you have submitted medical records so the 
claim can be processed. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no approved 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 physician services provided on November 17, 
2021, and November 23, 2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-rays of the spine provided on December 
3, 2021. 
 
You asked the Plan to waive the copayment for the X-rays. 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 $25 
copayment for diagnostic procedures and tests in a specialist's office.  
 
You have been asked to pay a $25 copayment for the X-rays. The X-rays fall within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies 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 X-rays of the spine provided on December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on June 25, 
2021 and July 8, 2021. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you should not have to pay 
for all the laboratory visits because the laboratory could not locate your initial bloodwork. The Plan denied 
your request. The Plan says copayment 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 $10 
copayment for diagnostic laboratory services and diagnostic procedures and tests (per day, per facility).  
 
  You have been asked to pay a total of $20 for laboratory services ($10/visit x 2 visits = $20). Laboratory 
service falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 laboratory services provided on June 25, 2021 and July 8, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive metabolic panel provided on November 19, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Comprehensive metabolic panel. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and it 
was determined these services were not urgent or emergent. 
 
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 Comprehensive metabolic panel provided on 
November 19, 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 an orthosis (L2397, L1851) provided November 10, 2021. 
 
You asked the Plan to pay for the orthosis. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the enrollee's physician denies ordering this item. The item was provided in 
an unsolicited fashion to the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthosis have 
not been met. Therefore, we decided that the Plan does not have to pay for an orthosis (L2397, L1851) 
provided November 10, 2021.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you do not have documented skilled nursing needs. You do not have documented 
skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or 
to prevent deterioration of your condition. 
 
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.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydrocodone/Acetaminophen. 
 
You asked the Plan to pre-approve Hydrocodone/Acetaminophen. You say that the medication is necessary. 
The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a 
separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 
Hydrocodone/Acetaminophen.  
 Benefits for Hydrocodone/Acetaminophen may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services provided on December 13, 
2021. 
 
You asked the Plan to pay for the pain management services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the records do not support the 
services billed. 
 
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 pain management services 
provided on December 13, 2021 have been met. The records provided do not show the date of service at issue 
in this appeal. Therefore, we decided that the Plan does not have to pay for the pain management services 
provided on December 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Orthovisc, Synvisc or Synvisc-one first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has osteoarthritis of the knee. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided 
August 5, 2021. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the enrollee was an inpatient at the time the item was 
provided and it is not eligible for separate payment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression device was used in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided August 5, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81321, 81206, 81210, 81235, 81272, 81275, 
81276, 81292, 81301, 81311) provided June 6, 2021.   
 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says these codes are not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays two or more genes in a 
patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes 
a single procedural service, so one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81321, 81206, 81210, 81235, 81272, 
81275, 81276, 81292, 81301, 81311) provided June 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the enrollee needs Botox for senile entropion of the 
right lower eyelid. The Plan denied your request. The Plan says it is not medically appropriate or reasonable to 
administer Botox for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found based on the medical records provided 
and the Medicare-approved major drug compendia there is no documentation that the Botox meets Medicare 
criteria for medically reasonable and necessary for the patient. Entropion of the eyelid is not documented as a 
medically accepted indication for Botox in the Medicare-approved major drug compendia. 
 
 
 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) and surgical tray (A4550) provided 
October 6, 2021. 
 You asked the Plan to pay for the office visit and surgical tray. You say that the services billed were medically 
necessary. The Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code A4550 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code A4550 is not separately payable. Code 99204 has a MUE of 1, however 2 units were billed. Based on this 
information, we decided that Medicare rules for coverage of the office visit and surgical tray have not been 
met. Therefore, we decided that the Plan does not have to pay for an office visit (99204) and surgical tray 
(A4550) provided October 6, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided to the enrollee from November 17, 
2021, to December 3, 2021. 
 
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 Original Medicare would be responsible for payment of all Medicare covered services related or 
unrelated to the enrollees terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital services provided to the enrollee from November 17, 
2021, to December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 the laboratory 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 provided on May 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as 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. 
 
 
 
  
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services provided on October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789) provided February 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing.  
 
We looked at the file and Medicare rules. The billed service is validity testing on a urine specimen for drug 
testing. This service is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met.  
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for lab services (83789) provided February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99156 and 99157) provided 
on November 23, 2021. 
 You asked the Plan to pay for codes 99156 and 99157. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as 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, we have confirmed that codes 
99156 and 99157 are column II codes to column I code 27266 with a modifier indicator of 0. The column II 
codes are therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99156 and 99157) 
provided on November 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 17, 
2021. 
 
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 an appropriate modifier was not billed with this edit. 
 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 70460 
is a column II code to column I code 0042T. 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 imaging services provided to the enrollee on September 17, 
2021.