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

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA) 
(87633) provided November 3, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says Multiplex PCR respiratory viral panels 
of 6 or more pathogens are non-covered. 
 
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 87633 is infectious agent detection by nucleic acid (dna or rna); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, 
respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and 
multiplex amplified probe technique, multiple types or subtypes, 12-25 targets. 
 
We find that CPT code 87633 is not supported in the medical record. Specifically, per Local Coverage Article 
A58575, this is a group 2 code that is not covered. Based on this information, we decided that Medicare rules 
for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to 
pay for the infectious agent detection by nucleic acid (DNA or RNA) (87633) provided November 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's needs 
can be met at a lower level of 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 enrollee is medically stable and no acute or complex rehab nursing needs are 
noted in the record. While the enrollee may benefit from physical and occupational therapy, the enrollee's rehab 
needs can be safely met in an alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on February 10, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you do not feel that you should 
have to pay for service from a doctor whom you did not invite into your room, and who you do not ever go see, 
and do not know where his office is. The Plan denied your request. The Plan says you were 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 $35 
copayment for each specialist visit, including outpatient clinic visits.  
 
 
 
 
 
 You have been asked to pay a $35 copayment for each specialist visit, including outpatient clinic visits for an 
office visit. An office visit 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 an office visit provided on February 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging on February 
8, 2022. 
 
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says the cost share applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for myocardial perfusion imaging.  
 
You have been asked to pay a $275 copayment for myocardial perfusion imaging. Myocardial perfusion 
imaging 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 myocardial perfusion imaging on February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 3, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this service was not billed as required by 
Medicare coding regulations. 
 
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 laboratory services provided on 
December 3, 2021, have been met. In this case, no medical records from the ordering provider have been provided. Without these medical records, the medical necessity of the ordered testing cannot be ascertained.  
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 3, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a new patient office visit provided on 
July 29, 2021. 
 
You asked the Plan to waive the copayment for a new patient office visit. The Plan denied your request. The 
Plan says the claim paid 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 
copayment for Physician/Practitioner services, including doctors office visits-Specialist office.  
 
You have been asked to pay a $35 copayment for a new patient office visit. The new patient office visit falls 
within the Physician/Practitioner services, including doctors office visits-Specialist office 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 new patient office visit provided on July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 31, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 payment for the billed CPT codes is not supported in the medical record. Specifically, these codes 
are assigned a PC/TC indicator of 1. In this case, the services must be billed with modifier -26 for payment to 
be considered. Based on this information, we decided that Medicare rules for coverage of the services have not 
been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 31, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
January 18, 2022, to January 20, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you cannot afford the 
copayment. 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 $200 per 
day for days 1-5 and $0 per day after day 5 for each inpatient admission.  
 
The file shows that you were in the hospital from January 18, 2022, to January 20, 2022, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $200 per day for the first 2 days of 
inpatient care. The total for your stay is $400 ($200 copayment x 2 days = $400). The inpatient care falls within 
the Inpatient Hospital 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 inpatient hospital care provided from January 18, 2022, to 
January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided on March 14, 2022. 
 
You asked the Plan to pay for an ankle-foot orthosis. You say that the item at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the patients medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical records do not discuss the item at issue. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for an ankle-foot orthosis (L1971) provided on March 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI's) of a 
leg joint and lower spinal canal provided on February 23, 2022. 
 
You asked the Plan to waive the copayment for the MRI's. You say that you were informed there was no 
copayment since it was authorized. 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 $200 
copayment for advanced imaging services, such as MRI's.  
 
You have been asked to pay a $200 copayment for the MRI's. The MRI's 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 magnetic resonance imaging (MRI's) of a leg joint and lower spinal canal provided on February 23, 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 the LTACH services. You say that the enrollee meets Medicare criteria for 
LTACH level of care. The Plan denied your request. The Plan says the enrollee's medical records show they do 
not meet the Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to an acute care facility on May 22, 2022, with 
decompensated congestive heart failure and hypoxia requiring intubation and mechanical ventilation. There is 
no documentation provided indicating medical necessity for admission to a LTACH. The 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 they are currently receiving care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2303, V2750, V2781) provided on 
March 3, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that you should not be liable for this amount. The Plan 
denied your request. The Plan says this claim was processed correctly, and your portion of the bill was assessed 
in accordance with your contract. The Plan pays up to $200 for routine eyeglasses, and you are responsible for 
the remaining cost. 
 
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 up to a $200 allowance every calendar year. 
 
We looked at the file and the Plan's rules. The record shows that the full billed cost of the eyeglasses received 
on March 3, 2022, was $571. The Plan paid the full $200 allowance amount, and you are being asked to pay the 
remaining cost of $371. This means that you have been asked to pay the correct amount for the routine 
eyeglasses based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for 
the eyeglasses (V2020, V2303, V2750, V2781) provided on March 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT), 
multiple studies (78452). 
 
You asked the Plan to pre-approve SPECT studies. You say that this test is medically necessary. The Plan 
denied your request. The Plan says the criteria for SPECT imaging are not met in this case. The documentation 
does not show that the enrollee has had other tests for the heart that were unclear. There is no documentation of 
other stress tests that were not normal or that the enrollee was unable to have other stress tests. The 
documentation does not suggest that the results of this test will change the understanding of the risk of surgery. 
 
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 SPECT studies. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of chest pain felt by the physician to be non-cardiac. The enrollee's 
pre-test probability for an abnormal test is low and there is no documentation that his electrocardiogram (ECG) 
shows an uninterpretable pattern. There is no evidence provided that would support the need for radionuclide 
stress testing in the enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT studies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging, tomographic (SPECT), multiple studies (78452).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on 
November 2, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this should be covered since 
the first hospital had no beds available. The Plan denied your request. The Plan says the copayment applied 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 $300 
copayment for each one-way Medicare covered trip.  
 
You have been asked to pay $300 copayment for ambulance transport. Ambulance transport 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 transport provided on 
November 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 8, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.   
We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one 
previously processed and paid by the Plan. Duplicate claims are not payable. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the services provided on January 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the PT visit provided on January 27, 2022. 
 
You asked the Plan to waive the copayment for the PT visit. You say that you were not told there would be a 
copayment. The Plan denied your request. The Plan says the copayment was applied 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 $30 
copayment for Medicare-covered physical therapy in-person visits.  
 
You have been asked to pay $30 for the PT visit. The PT visit falls 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 copayment for the physical therapy (PT) 
visit provided on January 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service February 25, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date. 
The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for code 93976.  
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 76700 
is a column II code to column I code 93976. 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 76700 billed for date of service February 25, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered 
by Medicare due to insufficient evidence of efficacy. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The intracept 
procedure is experimental. More research is needed. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the services have 
been provided out-of-network and were not approved in advance. 
 
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 office visit provided on February 14, 2022, by 
an out-of-network (OON) provider.