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

 
We decided that the Plan does not have to waive the copayment for cardiology services provided on March 1, 
2022. 
 
You asked the Plan to waive the copayment for the cardiology services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $50 copayment for the cardiology services. Cardiology 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 cardiology services provided on March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for. parenteral nutrition administration kit, per day (B4224) and parenteral 
nutrition supply kit; premix, per day (B4220) provided December 23, 2021 to December 29, 2021 
 
You asked the Plan to pay for. the parenteral supplies. You say that B4220 and B4224 denied for date and units 
not matching. These 6 TPN bags were infused over 7 days. The Plan denied your request. The Plan says that 
exceeds the contracted maximum number of hours/days/units by this provider for this period. 
 
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. the Plan has not provided documentation to substantiate their reason to deny. 
The records provided shows that the Plan had approved payment of the same CPT codes B4224 (7 units) and 
B4220 (7 units) for dates of service 11/25/2021 to 12/01/2021 and dates of service 12/09/2021 to 12/15/2021. 
The records show that the units billed in this case is for 6 units. The Plan has not provided any information or 
rules to show how much is allowed and how the units was exceeded. Therefore, we decided that the Plan has to 
pay for. parenteral nutrition administration kit, per day (B4224) and parenteral nutrition supply kit; premix, per 
day (B4220) provided December 23, 2021 to December 29, 2021  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87653, 87641, 87798) provided September 15, 
2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 codes 87653, 87641, & 87798 are not supported in the medical record. Specifically, the 
records provided do not support that these services were performed. 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 (87653, 87641, 87798) provided September 15, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not indicate ongoing daily skilled needs and the enrollee's needs can 
be met with home health services and the other needs are custodial in nature 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested admission is medically reasonable and necessary. Our physician reviewer found that the clinical 
documentation shows that the enrollee has skilled nursing needs due to the need for medical monitoring. It is 
also shown that the enrollee has new functional impairments and requires skilled therapy. The evaluating 
physical therapy recommends daily skilled therapy in a skilled nursing facility (SNF). From a practical matter, 
the records show that the enrollee requires daily skilled services in a skilled nursing 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 
64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in the setting 
of chronic vertebrogenic low back pain have not been demonstrated in the peer-reviewed literature. The Plan 
states more research is needed to show safety and efficacy of the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental and more research is needed. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 64629).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from November 5, 2021, to December 4, 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 ongoing skilled care could have been provided in an alternative setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that 
there are no identifiable skilled nursing service needs. There were no identifiable skilled therapy service needs. 
The enrollee did not require skilled nursing or therapy services on a daily basis. The enrollee did not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from November 5, 2021, to 
December 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you're having trouble walking and mostly 
bedridden, you require inserts to start walking again and better your health. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on January 20, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the PT services. The Plan denied your request. The Plan says these services were 
rendered by an OON provider. The Plan also says these services were not authorized and are not payable by the 
Plan. 
 
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 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 physical therapy (PT) services provided on 
January 20, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 22, 
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 this procedure code is inclusive to CPT code 49505. 
 
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 is "Excision of lesion of spermatic cord (separate 
procedure)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative report describes 
excision of spermatic cord was performed in order to reduce the hernia sac. In this case, CPT 55520 would be 
inclusive to the hernia repair as this procedure was performed in order to perform the hernia repair. If the 
documentation supports increased procedural services, there is an appropriate modifier to append to the procedure code. 
 
We looked at this coder's review, the file, and Medicare rules. 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 surgical services provided to the enrollee on October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789, 80307, G0480) provided on February 
10, 2022. 
 
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 there were network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 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 lab services (83789, 80307, G0480) provided on February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for compounded drugs (J3490, J1170, J3490) provided October 
26, 2021. 
 
You asked the Plan to pay for the compounded drugs. You say that the drugs 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 codes J3490, J1170, & J3490 are not supported in the medical record. Specifically, separate 
unbundled codes were submitted for a single compound. This service must be billed using the code for 
compounded drugs (J7999). Based on this information, we decided that Medicare rules for coverage of the 
compounded drugs have not been met. Therefore, we decided that the Plan does not have to pay for 
compounded drugs (J3490, J1170, J3490) provided October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization (CPT code(s): 37221, 37220, 75710, 
73223). 
 
You asked the Plan to pre-approve the services. You say that the services should be approved. The Plan denied 
your request. The Plan says there is no documentation of the need for magnetic resonance imaging (MRI) of 
your shoulder, elbow, wrist or finger joints. The Plan state they believe the authorization department if your 
doctor's office entered the wrong code in the computer for a test that they wish to do. The Plan states there are 
MRI and MRA examinations that image the veins and arteries in the lower extremity. The Plan states they 
contacted your doctor's office to see if they wish to change this to a different exam, but they confirm that doubt 
was correct. The Plan states they then asked for records to see if there was an examination of your arms that 
might justify and MRI; however, the examination and diagnosis is only for your leg. The Plan states if your 
doctor wishes to perform an examination of the veins and arteries in your legs, and request the code for those 
tests, the Plan will review based on your medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. The Plan contacted the provider's office and your provider's office 
stated they are not requesting these CPT code(s): 37221, 37220, 75710, 73223)). Your provider's office has 
requested these specific CPT code(s): 37238, 37239, 75822 from the Plan. The Plan approved these CPT code(s): 37238, 37239, 75822 only. Therefore, revascularization (CPT code(s): 37221, 37220, 75710, 73223) 
are not approved because they are not the correct codes. Therefore, we decided that the Plan does not have to 
pre-approve revascularization (CPT code(s): 37221, 37220, 75710, 73223).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this was a medically appropriate visit. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says 
that they have also determined that these services are not urgent or emergent, nor were they 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 an office visit provided on March 23, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Shoulder elbow wrist hand orthosis (L3960) provided April 
18, 2022. 
 
You asked the Plan to pay for the orthosis. You say that this claim should have been paid. All of Medicare's 
DME requirements were met. The Plan denied your request. The Plan says services is not documented in the 
enrollee's medical records. 
 
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 Shoulder elbow wrist hand orthosis (L3960) provided April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this was a medically appropriate visit. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says 
that services were not referred by a network provider or rendered in an in-network facility. The Plan also says 
that they have also determined that these services are not urgent or emergent, nor were they 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 an office visit provided on February 14, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network (OON) specialist office 
visit provided on January 19, 2022. 
 
You asked the Plan to waive the copayment for the OON specialist visit. You say that you should not have to 
pay because of the "No Surprises Billing Act". 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 out-of-network specialist services.  
 
You have been asked to pay a $50 copayment for the OON specialist visit. The OON specialist visit falls 
within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. Please note that 
the law passed refer to balance billing, which does not apply to the copayment amount. 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 out-of-network (OON) specialist office visit provided on January 
19, 2022.