Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Durable medical equipment provided on 
December 21, 2021. 
 
You asked the Plan to waive the coinsurance for Durable medical equipment. You say that you were told you 
wouldnt be charged for any medical supplies and equipment. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for Durable medical equipment. This item/service falls within 
the Durable medical equipment (DME) 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 Durable medical equipment provided on December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract surgery provided on March 5, 2022, and March 10, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for cataract surgery. You say that you traveled out of the country and suffered a fall 
due to an episode of blindness due to your cataracts. You say that you had to see an Ophthalmologist in that 
country and were told you needed emergency surgery. The Plan denied your request. The Plan says the services 
provided outside of the country were not authorized. Per your provider the cataract was not at a stage of 
needing surgery. You did not meet rules for PRP injections, treatment was not for diabetic ulcers or any other 
qualifying wound that would benefit from PRP treatment. 
 
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 at issue in this case is not a network provider with the Plan. 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 cataract surgery. Our physician reviewer found there are no Ophthalmology 
exam notes available, specifically documenting visual acuity, slit lamp exam, or any urgency for cataract 
surgery. Enrollee letter 4/1/2022 states that "upon arrival to that country's airport, due to the blindness that I 
had, caused by a cataract in my right eye, I fell and bruised my left knee." Enrollee indicates that the cataract 
was already present and pre-existing. Enrollee indicates they were taken to a clinic and told they needed 
"immediate" surgery because the cataract was "too advanced." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cataract surgery have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pay for cataract surgery. Therefore, we decided that the Plan does 
not have to pay for cataract surgery provided on March 5, 2022, and March 10, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services (99203, 72100, 72040) you received 
on March 16, 2021. 
 
You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your 
request. The Plan says these services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic services (99203, 72100, 72040) you received on March 
16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ABI study provided on July 26, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the ABI study. You say that the ABI study was performed due to poor palpable 
pulses and patient comorbidities. The Plan denied your request. The Plan says the out-of-network services were 
not authorized. 
 
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 ABI study provided on July 26, 2022, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on June 29, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that since this is related to COVID-19 it 
should be covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for Medicare-covered primary care doctor visit. 
 
You have been asked to pay a $15 copayment for office visit. This item/service falls within the Medicare-
covered primary care doctor visit 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 
office visit provided on June 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services received on May 19, 
2022, and May 20, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the 100-day SNF benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from February 5, 
2022, to May 18, 2022. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services received on May 19, 2022, and 
May 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) provided on June 21, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says there is insufficient documentation to support the billed services. 
 
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 genetic testing have been met. No 
clinical records were provided. The documentation only included lab results. The plan requested additional records and none were provided. Therefore, we decided that the Plan does not have to pay for genetic testing 
(0037U) provided on June 21, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the prosthetic device, provided on 
December 4, 2020, and the copayment for the emergency room services, provided on July 21, 2022. 
 
You asked the Plan to waive the coinsurance for the prosthetic device and the copayment for the emergency 
room services. You say that there should not be any cost share. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Prosthetic devices and related supplies and a $90 copayment for emergency room services.   
You have been asked to pay a 20% coinsurance for the prosthetic device and $74.29 out of a $90 copayment 
for emergency room services. These services fall within the Prosthetic devices and related supplies and 
emergency room benefit categories. 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 the prosthetic 
device, provided on December 4, 2020, and the copayment for the emergency room services, provided on July 
21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 20, 2022, to February 18, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the claim must be completed 
for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the required 
NOA document is required in order to process the final home health claim. Review of the file shows that the 
required NOA was not submitted. Therefore, we decided that the Plan does not have to pay for the home health 
services provided to the enrollee from January 20, 2022, to February 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
July 27, 2022. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that the chart notes support the 
charges were billed correctly and there were no bundling issues. You say that the claim should be reprocessed 
to pay. The Plan denied your request. The Plan says procedure codes 20930 and 20936 are considered bundled 
and not separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical examination of the eye (92014) provided on 
August 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a medical examination of the eye (92014). You say that you have been seeing 
this provider for over 10 years. You also say you never needed a referral before. The Plan denied your request. 
The Plan says the services were rendered by a non-participating provider and prior authorization was not 
obtained. 
 
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 medical examination of the eye (92014) 
provided on August 8, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B drugs and outpatient 
surgery provided on March 23, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B drugs and outpatient surgery. You say that they 
overcharged you and you shouldn't have to pay this much. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs and a $275 copayment for services provided in an 
ambulatory surgical center. 
 
 You have been asked to pay a total of $223.39 (20% x $1,116.93) which is 20% of the allowed amount for 
Medicare Part B drugs. You have also been asked to pay $275 copayment for outpatient surgery. This 
item/service falls within the Medicare Part B prescription drugs and Outpatient surgery, including services 
provided at hospital outpatient facilities and ambulatory surgical centers benefit categories. 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 cost share for Medicare Part B drugs and outpatient surgery provided on March 23, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expects that the enrollee's necessary hospital care will 
span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture (97810, 97811, and 9026), provided on 
November 22, 2021. 
 
You asked the Plan to pay for the acupuncture. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the service was performed by an unsupervised acupuncturist. 
 
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, treatments may be provided by a physician in 
accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and 
auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture 
must be under the appropriate level of supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist. This service was performed by a non-covered provider. Therefore, we 
decided that the Plan does not have to pay for the acupuncture (97810, 97811, and 9026), provided on 
November 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure codes 63012, 63047, 63057) 
provided to the enrollee on January 31, 2022. 
 
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 the denied codes cannot be verified. 
 
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 the denied codes is: 
 
CPT 63012: 
 
Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda 
equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) 
 
 
 CPT 63047: 
 
Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda 
equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar 
 
CPT 63057: 
 
Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated 
intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to 
code for primary 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 records do not support CPT 
63012, 63047 63057 as separate and distinct procedures from CPT 22633. The procedure detailed report cited 
decompressive laminectomies/laminotomies with mesial facetectomies were done from T11-S1. At the L4-5 
level, a Gill-type decompression was done. All bone was removed using the Horsley bone cutter, Leksell 
rongeurs, various sized Kerrison rongeurs, and the high-speed pneumatic drill. This bone was morselized and 
saved for later use. Additional bone and marrow aspirate was also harvested through separate percutaneous 
fascial incision, morselized, and combined with local autograft and saved for later use. Neural elements were 
directly and indirectly decompressed. This was performed as part of the main procedure. 
 
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 (procedure codes 63012, 63047, 63057) provided to the enrollee on January 
31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 28, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 13, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 28, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on April 4, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the radiology services. You say that the provider depends upon the office staff to 
verify eligibility and to obtain the proper authorization from the patient's insurance. The Plan denied your 
request. The Plan says the out-of-network services were not authorized. 
 
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 radiology services provided on April 4, 2022, by 
an OON provider.