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

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on May 17, 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 the denied codes remain not supported. 
 
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 15734: 
 
Muscle, myocutaneous, or fasciocutaneous flap; trunk 
 
CPT 20999: 
 
Unlisted procedure, musculoskeletal system, general 
 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 in terms of CPT 15734, the operative 
report does not describe per NCCI Policy Manual, a prepared flap rotated from the donor area to the site 
needing repair, suturing in place. CPT 15734 cannot be verified. In terms of CPT 20999, the operative report 
does not describe an unlisted procedure code. The documentation is not clear on procedure performed to 
support an unlisted 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 May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hearing test (92587) provided on 
December 23, 2021. 
 
You asked the Plan to waive the copayment for the hearing test. You say that you thought you had a $0 
copayment for a hearing aid evaluation, and do not understand how this is different from a hearing test. The 
Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed 
in accordance with your contract. 
 
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 $25 
copayment for an annual routine hearing test.  You have been asked to pay a $25 copayment for the hearing test. 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 hearing test (92587) provided on December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5050) purchased on December 11, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that the cost was nearly half as much at this provider, 
and you should not be punished for seeking more cost-effective options. The Plan denied your request. The 
Plan says the provider in this case is out-of-network. The hearing aids were not pre-approved for out-of-
network and there were in-network providers who could have provided these items/services. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are received in-network or pre-approved out-of-network.  
 
 
 
 
 
 
 
 We looked at the file and the Plan's rules. The hearing aids in this case were purchased out-of-network and 
were not pre-approved by the Plan. Based on this information, we decided that the Plan's rules for coverage of 
the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing 
aids (V5050) purchased on December 11, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the routine eye exam (S0620) and contact lens fitting/prescription 
(92310) provided on July 2, 2021. 
 
You asked the Plan to pay for the routine vision services. You say that you do not understand how contacts can 
be labelled cosmetic and denied when they are necessary to help you see. The Plan denied your request. The 
Plan says that these services are not covered. 
 
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. 
 
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 one routine eye exam per calendar year and up to $150 toward prescription eye wear 
(glasses, contacts, lenses, frames and upgrades) once per calendar year. 
 
We looked at the file and the Plan's rules. The Plan states that these services are denied as they are not covered 
by Original Medicare. However, the Plans contract clearly states that there is a supplemental benefit to cover 
routine vision services, including an annual routine eye exam and a $150 allowance toward the cost of eye 
wear.  The Plan has not provided any other argument or evidence to support why these services should be denied. 
Based on this information, we decided that the Plan's rules for coverage of the routine vision services have been 
met. Therefore, we decided that the Plan has to pay for the routine eye exam (S0620) and contact lens 
fitting/prescription (92310) provided on July 2, 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: Transportation
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for air ambulance services. We also decided that the 
Plan does not have to fully waive the coinsurance for air ambulance services.  
 You asked the Plan to waive the coinsurance for air ambulance services. You say that you are on a fixed 
income and cannot afford the cost share. The Plan says that you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for air ambulance services.  
 
The Plan says you must pay $775.52 for air ambulance services. Based on the Plan contract, however, you 
cannot be asked to pay more than 20% coinsurance for air ambulance services. The record shows the Plan 
calculated the coinsurance incorrectly. Air ambulance services fall within the Ambulance Services benefit 
category. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan has to reduce the coinsurance but does not have to fully waive the 
coinsurance for air ambulance services provided on November 28, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Speech Therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve Speech Therapy. You say that The member has progressively worsening 
cognitive dysfunction, requiring assistance with ADLs, was seen by geriatric medicine few months ago with 
low Moca score. Most likely suffers from dementia. The Plan denied your request. The Plan says coverage 
does not provide out of network when there are in-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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 pre-approve Speech Therapy. Our reviewer says that the service is not medically 
necessary. Our physician reviewer found the documentation does not reveal a significant change in the patient's 
cognitive communicative or swallowing skills that would require skilled speech therapy x 12 sessions. The patient's condition could have been foreseen requiring the services prior to leaving his service area. The patient 
would be limited in carryover due to less than 25% short term, long term and procedural memory.  
Additionally, without a significant change in patient's condition the requested ST sessions were not medically 
necessary and additionally could have been met with in network providers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Speech Therapy 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 pre-approve Speech Therapy. Therefore, we decided that the Plan 
does not have to pre-approve Speech Therapy to be provided by an out-of-network (OON) provider.
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 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 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care facility. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 serviceshave not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on January 26, 
2022, and February 1, 2022. 
 
You asked the Plan to waive the copayment for the office visit. 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% 
coinsurance for Physician/Practitioner services, including doctors office visits.  
 
 
  You have been asked to pay a 50% coinsurance for two out-of-network office visits (total allowed is $176.26 x 
50% = $88.13). 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 January 26, 
2022, and February 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a diagnostic mammogram (code 77065) 
provided on November 22, 2021, and a diagnostic mammogram (code 77065) and breast tomosynthesis (code 
G0279) provided on November 22, 2021. 
 
You asked the Plan to waive the cost share for a diagnostic mammogram. You say that this was a routine 
mammogram. You also say that a cost share was applied to the mammogram of your right breast, but the left 
breast was a preventative exam. 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. Your 
contract with the Plan says that there is $750 deductible which applies to outpatient diagnostic testing. The Plan 
contract also says that enrollees must pay a $10 copayment for basic imaging services after the deductible is 
met.  
The medical record shows you had a diagnostic mammogram on November 22, 2021. The diagnostic 
mammogram you asked the Plan to waive the cost share for falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. You have been asked to pay $94.62 towards your 
deductible for a diagnostic mammogram (code 77065). You have also been asked to pay $29.38 towards your 
deductible for a breast tomosynthesis (code G0279). You have been asked to pay a total of $124 which was 
applied to your deductible ($94.62 + $29.38 = $124). The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $750 deductible which applies to outpatient diagnostic testing.  
 
You have also been asked to pay $9.62, which is less than the $10 copayment for a diagnostic mammogram 
(code 77065).  You have been asked to pay a total of $133.62 ($124 deductible + $9.62 copayment = $133.62). 
This cost sharing is a contractual obligation that had not been met at the time a diagnostic mammogram was 
received on November 22, 2021. Therefore, we decided that the Plan does not have to waive the cost share for 
a diagnostic mammogram (code 77065) provided on November 22, 2021, and a diagnostic mammogram (code 
77065) and breast tomosynthesis (code G0279) provided on November 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from June 18, 2021, to 
June 24, 2021. 
 
You asked the Plan to pay for the services. You say that these services were medically necessary and are 
supported in the record. The Plan denied your request. The Plan says DRG 690 is more appropriate in this case.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 689 (KIDNEY AND URINARY TRACT 
INFECTIONS WITH MCC). 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 supported by the medical records. Our physician 
reviewer found the documentation was difficult to read, as dates of service are not clear, and documentation 
appears to be a constant run of notes. Throughout this hospital stay, encephalopathy was not consistently 
documented with medical management plan for this specific diagnosis. The documentation supports urinary 
tract infection, which confusion is a sign/symptom. No discharge note was found in the documentation. In this 
case, the documentation does not support level of service billed.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital care provided from June 18, 2021, to June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmology exam provided on July 19, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmology exam. You say that the service was medically necessary. The 
Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the ophthalmology exam provided on July 19, 2021, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on September 
30, 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 the medical records do not contain documentation of definitive laboratory results for 22 or more 
drug classes, including metabolites to support the coding criteria for G0483 for the billed date of service 
9/30/2021. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a urine screening test was ordered on 9/30/21, however, there was no provided list of drug classes 
ordered to specify 22+ drug classes ordered on that date. Also, this extensive definitive testing was not 
supported in the documentation as there was no report of likely drug abuse, prescription misuse, or abnormal 
results from a screening urine drug test just prior to this testing. The definitive drug test will be considered not 
medically necessary based on the above. 
 
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 drug testing services provided to the enrollee on September 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical spine surgery to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve cervical spine surgery to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. 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 pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
cervical spine surgery to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional twelve (12) Aqua physical therapy (PT) 
visits (97161, 97110, 97140, 97162). 
 
You asked the Plan to pre-approve additional aqua PT visits. You say that the requested additional aqua PT 
visits are medically necessary. The Plan denied your request. The Plan says the requested additional aqua PT 
visits do not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 additional aqua PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the enrollee has had prior therapy and the documentation 
does not reveal that she requires the unique skills of a professional therapist to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The enrollee should be able to transition to a land-based therapy program. She has 
been instructed in home exercises. The requested services are not part of a maintenance program, and the 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. There 
has been instruction in an independent home program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional aqua PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional twelve (12) Aqua physical therapy (PT) visits (97161, 97110, 
97140, 97162).