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

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on August 13, 
2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you are asking the Plan to 
review and reconsider payment. 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 $65 
copayment for urgently needed services. 
 
You have been asked to pay a $65 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 an urgent 
care visit provided on August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for spinal injections provided on March 31, 
2022. 
 
You asked the Plan to waive the copayment for spinal injections. You say that you have never had to pay for an 
injection before and do not feel you should have to pay for one now. 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 $45 
copayment for outpatient hospital services. 
 
You have been asked to pay a $45 copayment for spinal injections. This item/service falls within the outpatient 
hospital 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 spinal injections 
provided on March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0481) provided on March 31, 2022. 
 
You asked the Plan to pay for the drug testing (G0481). 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 billing of 
code G0481. 
 
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 G0481 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed.  
We find that CPT code G0481 is not supported in the medical record. Specifically, the records show that only 7 
drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the drug 
testing (G0481) have not been met. Therefore, we decided that the Plan does not have to pay for the drug 
testing (G0481) provided on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray (77002) provided on May 17, 
2022 to June 28, 2022 
 
You asked the Plan to waive the copayment for the x-ray. You say that the services should be covered as you 
disagree with the charges. 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 $110 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
  You have been asked to pay an $80.79 copayment for the x-ray, which is less than the standard $110. This 
item/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 an x-ray (77002) provided on May 17, 2022 to 
June 28, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for frames (V2020), anti-reflective coating (V2750), lens sphere 
single plano (V2100), lens, polycarbonate or equal (V2784), and tint photochromatic (V2744), provided on 
April 25,2022. 
 
You asked the Plan to pay for frames (V2020), anti-reflective coating (V2750), lens sphere single plano 
(V2100), lens, polycarbonate or equal (V2784), and tint photochromatic (V2744). You say that the last time 
you went to this provider was three years ago. You also say you were told that you were covered for a free 
examination plus $100 for new glasses. The Plan denied your request. The Plan says the member had these 
services rendered by an out-of-network provider. 
 
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 with an in-network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover these services when the services 
are provided by an in-network provider. The record shows these services were provided by an out-of-network 
provider. Based on this information, we decided that the Plan's rules for coverage of frames (V2020), anti-
reflective coating (V2750), lens sphere single plano (V2100), lens, polycarbonate or equal (V2784), and tint 
photochromatic (V2744) have not been met. Therefore, we decided that the Plan does not have to pay for 
frames (V2020), anti-reflective coating (V2750), lens sphere single plano (V2100), lens, polycarbonate or 
equal (V2784), and tint photochromatic (V2744), provided on April 25,2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 27, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 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. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 27, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services provided on April 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for therapy services. You say that your provider was out of the office and you could 
not get the preauthorization before the visit. The Plan denied your request. The Plan says there was no 
preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 therapy services provided on April 14, 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 a determination of refractive state (92015) provided on July 
27, 2022. 
 
  You asked the Plan to pay for a determination of refractive state (92015). You say that you went to an eye 
doctor because you had a physical problem with your eye, not a vision problem. You also say that you did 
agree with a vision test. The Plan denied your request. The Plan says eye refractions are only covered by your 
plan if performed by a participating Plan provider and performed as a routine screening. 
 
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 they are performed during a routine exam and by a Plan routine 
vision care optometrist. 
 
We looked at the file and the Plan's rules. The rules say that they only cover refractions when they are 
performed by a routine exam and by a Plan routine vision care optometrist. The record shows that this was not 
a routine exam. Based on this information, we decided that the Plan's rules for coverage of a determination of 
refractive state (92015) have not been met. Therefore, we decided that the Plan does not have to pay for a 
determination of refractive state (92015) provided on July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) provided by 
an oral surgeon. 
 
You asked the Plan to pre-approve an evaluation. You say that you need to see an oral surgeon as soon as 
possible. The Plan denied your request. The Plan says that a comprehensive oral evaluation is not covered 
when received by an oral surgeon. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit when received by an oral surgeon. Therefore, we decided that the Plan 
does not have to pre-approve a comprehensive oral evaluation (D0150) provided by an oral surgeon.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 36247, 36248, and 37242 provided on March 29, 
2022. 
 
You asked the Plan to pay for procedure codes 36247, 36248, and 37242. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says that the records do not 
support the services billed. 
 
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. In this case, the Plan provided no evidence that procedure codes 36247, 36248, 
and 37242 without modifier's were previously paid. We are unable to verify if these were duplicate claims. 
Therefore, we decided that the Plan has to pay for procedure codes 36247, 36248, and 37242 provided on 
March 29, 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: 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 IRF care is medically necessary.
The Plan denied your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs
can be met at a lower level of care such as a skilled nursing facility.

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 in this case, the complexity of the enrollee's nursing, medical and rehabilitation
needs do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues to have
a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however,
the documentation doesn't support that she would meet criteria for admission to an acute inpatient
rehabilitation facility.

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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hand brakes and a basket for a walker. 
 
You asked the Plan to pre-approve hand brakes and a basket for a walker. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that enhancement accessories for walkers are not a 
covered benefit. 
 
We looked at the file and Medicare rules. The requested hand brakes and basket are considered enhancement 
accessories. Enhancement accessories do not contribute significantly to the therapeutic function of the walker. 
Based on this information, we decided that Medicare rules for coverage of hand brakes and a basket for a 
walker have not been met. Therefore, we decided that the Plan does not have to pre-approve hand brakes and a 
basket for a walker.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service August 8, 
2022, to August 12, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service August 8, 2022, to August 12, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the thoracic spine (72146). 
 
You asked the Plan to pre-approve an MRI of the thoracic spine. You say that these imaging services are 
medically necessary to manage the enrollee's severe pain and provide further treatment. The Plan denied your 
request. The Plan says that they have agreed to pre-approve an MRI of the cervical spine. However, the MRI of 
the thoracic spine is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of the thoracic spine. Our 
reviewer says that the requested service is reasonable and necessary. Our physician reviewer found the enrollee 
continues to have upper back pain. A review of a report of an MRI from June of 2017 revealed a study which 
showed several paracentral disc protrusions at multiple levels. In this enrollee with persistent upper back pain 
and prior multi-level fusion of the cervical spine, the requested MRI studies of both the cervical and thoracic 
spine are appropriate and should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the thoracic spine have been met. Therefore, we decided that the 
Plan has to pre-approve magnetic resonance imaging (MRI) of the thoracic spine (72146).  
 
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 procedure codes 72141 and 72146 billed for date of service 
January 26, 2022. 
 You asked the Plan to pay for procedure codes 72141 and 72146. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says the payment for codes 
72141 and 72146 is included in the payment for codes 72156 and 72157. 
 
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 72141 
is a column II code to column I code 72156 and 72146 is a column II code to column I code 72157. Both code 
pairs have 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 procedure codes 72141 and 72146 billed for date of service January 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve brow ptosis repair. 
 
You asked the Plan to pre-approve brow ptosis repair. You say that your skin fold is resting on your eyelashes. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that brow ptosis repair is covered when the enrollee meets 
the following: 
1. Redundant eyelid tissue hanging over the eyelid margin resulting in pseudoptosis where the pseudo 
margin produces a central "pseudo-MRD" of 2.0 mm or less, or 
2. Redundant eyelid tissue predominantly medially or laterally that clearly obscures the line of sight in 
corresponding gaze. 
 
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 brow ptosis repair. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found you have diagnoses of brow ptosis (bilateral) and dermatochalasis of both upper 
eyelids. Marginal reflex distance (MRD) is recorded as 0mm bilaterally. The documentation does not 
demonstrate the brow ptosis as the external photos do not demonstrate that the brow is below the supraorbital 
rim. The documentation or photos provided do not support the pseudo MRD to be less than 2.0mm or less. The 
documentation does not support redundant eyelid tissue predominantly medially or laterally that clearly 
obscures the line of sight in corresponding gaze. Therefore, you do 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 brow ptosis repair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve brow ptosis repair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J1644 billed for date of service September 1, 
2021. 
 
You asked the Plan to pay for procedure code J1644. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says payment for code J1644 is bundled into payment for code 36581. 
 
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 J1644 
is a column II code to column I code 36581. 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 J1644 billed for date of service September 1, 
2021.