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

 
We decided that the Plan does not have to waive the copayment for an eye exam with photos (92250) provided 
on March 22, 2022. 
 
You asked the Plan to waive the copayment for the eye exam with photo. You say that the services should be 
covered as you disagree with the charges since the services did not work. The Plan denied your request. The 
Plan says the cost-sharing applied correctly based on the services provided and the copayment will apply 
regardless of how successful they were. 
 
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 $50 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 
  You have been asked to pay a $12.75 copayment for an eye exam with photos, which is less than the standard 
$50. 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 exam with photos (92250) provided on March 
22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (84450, 84460, 86803) rendered by 
the out-of-network (OON) provider on February 28, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (84450, 84460, 86803) rendered by the out-of-network 
(OON) provider on February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on February 
15, 2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you should not have to pay 
for laboratory services because they are related to your annual exam. The Plan denied your request. The Plan 
says coinsurance 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 $12 
copayment for Medicare-covered laboratory tests.  
 
 
 
 
 
 You have been asked to pay $12 copayment for laboratory services. The laboratory services fall within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. Laboratory services are 
considered a separate service. 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 February 15, 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 the enrollee needs long term care due to 
health issues. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 enrollee is receiving appropriate care at the present acute care hospital. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for dates of service October 31, 
2021, to November 2, 2021. 
 
You asked the Plan to pay for procedure code 99291. You say that you have provided medical records to 
support payment of this code. The Plan denied your request. The Plan says this code is not supported in the 
medical record. 
 
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 99291 is (evaluation and management of the critically ill 
or critically injured patient, first 30-74 minutes).  This is a timed code, meaning that the time spent on this 
critical care service must be documented in the medical record. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the medical record does not 
document the number of minutes spent on critical care, which is a requirement to support this code. Based on 
this information, we decided that Medicare rules for coverage of procedure code 99291 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99291 billed for dates of service 
October 31, 2021, to November 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says you do not use insulin with at least three daily injections. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
continuous glucose monitor (CGM) and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a bone growth stimulator provided on 
November 16, 2021. 
 
You asked the Plan to waive the coinsurance for a bone growth stimulator. You say that no one ever told you 
about the cost share amount you would be asked to pay. 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 20% 
coinsurance for advanced durable medical equipment, including bone growth stimulators.  
 
You have been asked to pay $905.81, which is 20% coinsurance of the allowed amount for a bone growth 
stimulator ($4,529.04 allowed amount x 20% coinsurance = $905.81). A bone growth stimulator falls within 
the Durable Medical Equipment (DME) and Related 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 coinsurance for a bone growth stimulator provided on November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on February 
15, 2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that you do not have a copayment for 
primary care. 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 $50 
copayment for lab services provided at an outpatient hospital facility.  
 
You have been asked to pay $42.09, which is less than the $50 copayment for the lab services. The lab services 
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 laboratory services provided on February 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery performed on February 2, 
2022. 
 
You asked the Plan to waive the copayment for the cataract surgery. You say that you feel the billing is 
incorrect. 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 $300 
copayment for surgery or procedure at an outpatient hospital facility.  
 
You have been asked to pay a $300 copayment for the cataract surgery. The cataract surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 cataract surgery performed 
on February 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve LTACH services. You say that LTACH admission is medically necessary as 
the enrollee has failed at a lower level of care and has had multiple re-admissions. The Plan denied your 
request. The Plan says the enrollee is receiving appropriate inpatient care at the current hospital and can remain 
there until ready for 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 that the enrollee does not require services at the LTACH that are not already 
available at the current 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 the LTACH services have not been met. 
  
 Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) 
services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from August 2, 2021, to August 19, 2021. 
 
You asked the Plan to waive the copayments for the PT services. You say that you were being treated for the 
wrong symptoms and finished therapy with a different provider. 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 $30 
copayment for each therapy visit.  
 
You have been asked to pay a $30 copayment for each of the 5 visits for the PT services provided from August 
2, 2021, to August 19, 2021. The total for the visits is $150 ($30 copayment x 5 visits = $150). The PT services 
fall within the Outpatient Rehabilitation 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 
copayments for physical therapy (PT) services provided from August 2, 2021, to August 19, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy performed on 
December 14, 2021. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you met your deductible and 
should not have been charged. 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 $250 
copayment for surgery or other services provided at an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay a $250 copayment for the colonoscopy. Please note that the copayment is the cost 
share applied after the deductible is met. The colonoscopy falls within the Outpatient Surgery, Including 
Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 diagnostic colonoscopy performed on December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve acupuncture services. You say that acupuncture is medically necessary for 
your low back pain. The Plan denied your request. The Plan says a licensed acupuncturist is a non-covered 
provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, a licensed acupuncturist is a non-covered provider 
type. Therefore, we decided that the Plan does not have to pre-approve acupuncture services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a catheter placement procedure performed 
on February 2, 2022. 
 
You asked the Plan to waive the copayment for the catheter placement. You say that the initial procedure was 
performed incorrectly and caused the need for a second procedure. 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 $250 
copayment for outpatient procedures and services.  
 
You have been asked to pay a $250 copayment for the catheter placement. The catheter placement falls within 
the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 catheter placement 
procedure performed on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array; peripheral nerve trial (excludes sacral nerve) (CPT 64555). 
 
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral 
nerve trial. The Plan denied your request. The Plan says percutaneous implantation of neurostimulator 
electrode array; peripheral nerve trial does not meet the Medicare coverage guidelines. 
 
The Plan follows Medicare rules. Medicare rules say that  
 
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 percutaneous implantation of 
neurostimulator electrode array; peripheral nerve trial. Our reviewer says that percutaneous implantation of 
neurostimulator electrode array; peripheral nerve trial is not medically necessary. Our physician reviewer found 
that current peer-reviewed data does not support PNS for fibromyalgia, phantom limb pain, diffuse 
polyneuropathy, nociceptive pain in trunk or lower back, or angina pectoris. Claims for these indications will 
be denied as not reasonable and necessary. Current peer-reviewed data also is insufficient to warrant the 
medical necessity of coverage for PNFS for any condition. Therefore, this service will not be covered for any 
condition. The review indicates that the enrollee is a 72-year-old female with bilateral low back pain since 
February of 2021. Conservative treatment includes bilateral injections, physical therapy, and medications. 
Imaging reveals: Multilevel mild disc degeneration of the lumbar spine without high-grade spinal. anal or 
neural foraminal stenosis multilevel facet arthropathy, greatest at L4-5 and L5-S1 Grade l anterolisthesis of L4-
L5 without abnormal motion. Trace retrolisthesis of L.2-3 without abnormal motion. The enrollee has not had a 
psychological evaluation. The review has determined that the requested percutaneous implantation of 
neurostimulator electrode array; peripheral nerve trial does not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array; peripheral nerve 
trial have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous 
implantation of neurostimulator electrode array; peripheral nerve trial (excludes sacral nerve) (CPT 64555).
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 enrollee fully meets criteria for IRF. The Plan 
denied your request. The Plan says the enrollee does not meet criteria and could be treated in a lower level of 
care facility such as a skilled nursing facility, outpatient setting, or home health care. 
 
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 the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute 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, and 
an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable 
expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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.