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

 
We decided that the Plan does not have to pay for a specialist office visit provided on January 11, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you are not in-network, but the enrollee 
was seen previously, and both those claims were paid in-network. You would like the claim to be reprocessed. 
The Plan denied your request. The Plan says the rendering and referring providers are both OON providers and 
there was no approved authorization. Also, the service rendered was not urgent or emergent and there are in-
network providers who provide the same service. 
 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 a specialist office visit provided on January 11, 
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 $35 copayment for  telehealth service provided on 
 January 19, 2022. 
 
You asked the Plan to waive the $35 copayment for telehealth services. You say that you did not ask to talk to 
the doctor and only asked for a refill for diabetic needles. You also say you might have been on the phone 1 to 
2 minutes and when you called last year you were not charged. The Plan denied your request. The Plan says 
you are responsible to pay a $35 copayment for each Medicare-covered Specialist visit. 
 
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 $35 
copayment for physician/practitioner services, including doctor's office visits.  
 
 
 You have been asked to pay a $35 copayment for telehealth services provided by a specialist. Telehealth 
services fall within the physician/practitioner services, including doctor's office visits 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 $35 copayment for telehealth services provided on January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (power operated vehicle, code K0800). 
 
You asked the Plan to pre-approve power scooter. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this device is correct, because this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that a power operated vehicle such as a power scooter is 
only covered if certain criteria are met. 
 
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 power scooter. Our reviewer says that 
the enrollee doe snot meet the Medicare criteria for a power scooter. Our physician reviewer found there is no 
indication that the enrollee requires a power mobility device to accomplish mobility-related self-care tasks in 
the home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter (power operated vehicle, code K0800).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing, 22 or more drug classes (G0483) 
provided December 20, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that you have enclosed the medical records or 
this date of service. Please review and process the claim. The Plan denied your request. The Plan says the 
records do not support the coding criteria. 
 
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 G0483 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 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; 22 or more drug class(es), including 
metabolite(s) if performed. 
 
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 laboratory service. Our reviewer says that the coverage 
criteria for the laboratory services were not met. Our reviewer found the laboratory report does not include 
documentation of 22 or more drug classes, and therefore cannot be verified. In this case, 19 drug classes were 
documented. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for definitive drug testing, 22 or more drug classes (G0483) provided December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a neurology specialist office visit provided 
on October 26, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that there should be no 
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 a $45 
copayment for an in-network specialist office visit.  
 
You have been asked to pay a $45 copayment for a specialist office visit. A specialist office visit falls within 
the Physician/Practitioner Services, Including Doctors Office Visits 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 neurology specialist office visit provided on October 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
(72195) provided on January 21, 2022. 
 
You asked the Plan to waive the copayment for the MRI. 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 $275 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $275 copayment for an MRI. MRIs 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) (72195) provided on January 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93976 billed for date of service January 18, 
2022. 
 You asked the Plan to pay for procedure code 93976. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 93976 is bundled into payment for 
code 76856 
 
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 93976 
is a column II code to column I code 76856. 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 93976 billed for date of service January 18, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement of nail(s) by any method (11720) provided on 
February 7, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the foo. You say that through an oversight in their staff, no prior authorization 
was obtained for this visit. This care was critical to this enrollee's overall health and well-being. The Plan 
denied your request. The Plan says enrollees must receive their medical services from an in-network provider 
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers 
require prior authorization before services being rendered. 
 
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 debridement of nail(s) by any method (11720) 
provided on February 7, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0667, E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says there is no documentation of a failed four week trial 
using E0650 or E0651 demonstrated by measurements. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0667, E0656).
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 currently meets the LTACH 
admission criteria. The Plan denied your request. The Plan says the LTACH services you are requesting do not 
meet the requirements for approval. 
 
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 patient does not require services at the LTACH that are not already available at 
the current facility. Our reviewer found that there are no services at the LTACH that the patient requires that 
are not already available and covered at the current facility. Our physician reviewer also found that transfer to a 
LTACH is not medically necessary as it would not be clinically advantageous at this time. 
 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve PET scan. You say that a PET scan is medically necessary as it provides a 
more accurate image of the enrollee's cancer. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this PET scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 PET scan. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a PET scan. Our physician reviewer found the enrollee does 
not have an indication for which a PET scan can be covered at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $35 copayment for x-rays taken on June 16, 2021. 
 
You asked the Plan to waive the $35 copayment for x-rays taken on June 16, 2021. You say that you paid your 
copayment for your office visit on June 16, 2021, and you later received a bill for a $35 copayment for x-rays 
taken that day. You also say that in the past your copayment for an office visit included everything. The Plan 
denied your request. You received other services during your office visit; therefore, you are responsible for a 
$35 copayment for each basic imaging service. 
 
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 outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  
You have been asked to pay a $35 copayment for x-rays. X-rays fall within the outpatient diagnostic tests and 
therapeutic services and supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. Please note, your contract with the Plan explicitly states that if 
you receive other services during an office visit, other cost sharing may apply. 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 $35 copayment for x-rays taken on June 16, 2021.
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. The Plan denied your request. The Plan says 
prolonged respiratory stability has not been established. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with acute respiratory failure and 
pneumonia. Recent notes describe the enrollee as now having successfully been extubated and tolerating low 
dose oxygen via trach collar and is tolerating PEG tube feeds. He appears to be more stable and improving and 
should only require short-term additional acute care services that can be safely completed at the current facility. 
There are no services at the LTACH that he requires that are not already available and covered at the current 
facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. 
 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart with 
quantitative evaluation of coronary calcium. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee will be motivated to lose 
weight if she has evidence for a need to do so. The Plan denied your request. The Plan says Medicare does not 
cover the requested study for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 The records provided do not include signs or symptoms of a specific disease or medical problem for which the 
testing would be warranted. The test at issue in this appeal is being requested for screening purposes. Medicare 
does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pre-
approve a computed tomography (CT) scan of the heart with quantitative evaluation of coronary calcium.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99231) provided on February 9, 
2022. 
 
You asked the Plan to pay for hospital care. You say that you would like the Plan to re-process this claim with 
modifier 24 added to this service. The Plan denied your request. The Plan says this service was provided and 
reported within the global period of major surgical procedure 33214 which was billed under a separate claim and provided on February 2, 2022. 99231 was not billed with an appropriate modifier indicating that this 
service was staged or unrelated to the post-operative period of a global procedure. This service is therefore 
bundled into the global surgical fee for 33214. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that 
Medicare criteria for coverage have not been met. Specifically, payment for CPT code 99231 is included in the 
global surgery package for CPT code 33214. Of note, CPT code 99231 has not been billed with the required 
modifier to indicate that this service would be separately payable. While the appeal request includes a note that 
modifier 24 be added and the claim be reprocessed, it does not appear that an official corrected claim with 
supporting documentation has been submitted directly to the Plan. Based on this information, we decided that 
Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (99231) provided on February 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services at a percutaneous transcatheter 
closure of the left atrial appendage (33340) provided on June 30, 2021. 
 
You asked the Plan to pay for assistant surgeon services. You say that assistant surgeon services were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says assistant surgeon services were 
not supported in the available medical records. 
 
The Plan follows Medicare rules. Medicare rules say that carriers pay for the assistant only if a review of the 
claim verifies medical necessity. 
 
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 assistant surgeon services. Our reviewer says 
that authorization of the participation of an assistant surgeon would not be considered medically reasonable and 
necessary in the enrollee's procedure. Our physician reviewer found that the operative note does not indicate 
any services that were specifically performed by the assistant surgeon. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of assistant surgeon services have not been met. Therefore, we decided that the 
Plan does not have to pay for assistant surgeon services at a percutaneous transcatheter closure of the left atrial 
appendage (33340) provided on June 30, 2021.