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

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on November 24, 
2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were told there was no doctor 
available. You say that nobody looked at your eye or took your blood pressure, so you went back home. The 
Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for emergency services in an emergency room.   You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the "Emergency care" 
benefit category. The records show you were seen in the ER. 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 ER visit provided on November 24, 2021.  
 
Your complaint about the provider telling lies is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you require additional therapies and are not 
medically stable to return home. The Plan denied your request. The Plan says the denial of authorization for 
SNF care is correct. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on December 10, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that it was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and 
there was no referral from an in-network provider or an approved authorization. Also, the service rendered was 
not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient services provided on December 10, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Angiography (75736-XU and 75736-76-XU) provided on 
October 20, 2021. 
 You asked the Plan to pay for codes 75736-XU and 75736-76-XU. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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. In this case, we have confirmed that code 75736 
is a column II code to column I code 37243. 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 the Angiography (75736-XU and 75736-76-XU) provided on 
October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision care services (92083, 92133) 
provided on November 11, 2021. 
 
You asked the Plan to waive the copayment for the vision care services. You say that the services should be 
covered as you disagree with the charges and usually do not pay a copayment for them. 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 $35 
copayment for Vision care.  
 
 
  You have been asked to pay a $35 copayment for vision care services. Based on your contract with the plan, 
copayment for vision care services is only waived when you receive a screening, the services received are for 
the treatment of your condition. 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 vision care services 
(92083, 92133) provided on November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99335) provided on 
November 30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this provider is not a network provider with the Plan, and 
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 a domiciliary or rest home visit (99335) provided 
on November 30, 2021, 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 26, 
2020. 
 
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 records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 35226 is "Repair blood vessel, direct; lower extremity." 
 
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 record indicates that the 
enrollee underwent amputation of the leg. The record does not indicate that the vessel in question was repaired 
as part of a distinct procedure and should not be billed separately. 
 
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 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (71045) provided November 7, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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. In this case, we have confirmed that code 71045 
is a column II code to column I code 74022. 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 radiology services (71045) provided November 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit provided on November 22, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the annual wellness visit. You say that the provider is part of the hospital's 
network of physicians. The Plan denied your request. The Plan says the services were provided out-of-network 
and were not approved in advance. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the annual wellness visit provided on November 
22, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on October 22, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that this service was necessary, and you cannot afford 
these bills. The Plan denied your request. The Plan says you had a previous eye refraction on September 21, 
2021, which was covered by the Plan. Your benefit covers one eye refraction per calendar year. 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 with refraction and dilation per calendar year. 
 
We looked at the file and the Plan's rules. The documentation shows that you had a previous eye refraction in 
September 2021, which was covered by the Plan. Based on this information, we decided that the Plan's rules for 
coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for 
the eye refraction (92015) provided on October 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on December 14, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgery services. You say that it was medically necessary to treat the enrollee 
and would like the claim adjusted for payment. The Plan denied your request. The Plan says the rendering 
provider is an out-of-network provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the surgery services provided on December 14, 
2021, 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 office visit provided on October 26, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that the visit was medically necessary. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not approved in advance. 
 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out-of-area urgent care, and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on October 26, 2021, by 
an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Laparoscopy (47562) provided on 
September 18, 2021. 
 
You asked the Plan to waive the copayment for the Laparoscopy. 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 $325 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
  
You have been asked to pay a $325 copayment for a Laparoscopy. Laparoscopies fall within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 Laparoscopy (47562) provided on September 
18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82728, 83540, 83550) provided September 27, 
2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the codes billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of End-stage Renal Disease (ESRD) are included in the ESRD PPS as Part B services and are 
not paid separately as of January 1, 2011. 
 
We looked at the file and Medicare rules. The codes billed are included in payment to the ESRD facility and 
not separately billable. 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 (82728, 
83540, 83550) provided September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided during a screening 
colonoscopy on November 2, 2021, billed with code 00811-AA-QS. 
 
You asked the Plan to pay for the anesthesia services as billed. You say that the records support that payment 
should be made. A corrected claim was also submitted. The Plan denied your request. The Plan says the 
corrected claim submitted was billed in the same manner as the original claim. Both claims were billed 
incorrectly for anesthesia provided during a purely screening colonoscopy. 
 
The Plan must follow Medicare rules. Medicare rules say that anesthesia for colonoscopies must be billed in a 
certain manner depending on whether the procedure is screening or diagnostic.  
 
 
 In this case, the records shows that the colonoscopy was provided for screening purposes and was not 
converted to a diagnostic procedure. As such, code 00812 should be used to report the anesthesia. Therefore, 
we decided that the Plan does not have to pay for the anesthesia services provided during a screening 
colonoscopy on November 2, 2021, billed with code 00811-AA-QS.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing provided to the enrollee on June 21, 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 predictive screening testing is not a Medicare-covered benefit. 
 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 test at issue in this appeal, the services, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. The test was done for clearance for a sleep study. The enrollee 
denied any symptoms, and there does not appear to have been an active exposure to the virus. Therefore, we 
decided that the Plan does not have to pay for COVID-19 testing provided to the enrollee on June 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional surgical services provided to the enrollee on 
September 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 this does not meet the criteria for Medically Unlikely Edits (MUE). 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 24600 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 additional surgical 
services provided to the enrollee on September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on November 16, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you had a referral for this visit from the patient's 
primary care provider (PCP), which you submitted to the Plan. The Plan denied your request. The Plan says 
they made an outbound call to the PCP on February 25, 2022 and determined a referral was not made for an 
out-of-network provider. The Plan also says that this provider is not a network provider with the Plan, and 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 (99213) provided on November 16, 
2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve administration of the drug (CPT code 96365) and 
Vyvgart 400MG/20ML solution (CPT code J3590). 
 
You asked the Plan to pre-approve the services. You say that the medication is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of Vyvgart in the setting of seronegative myasthenia 
gravis have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the services. Our physician reviewer 
found the documentation indicates that the enrollee has seronegative myasthenia gravis. The Medicare-
approved major drug compendia do not cite a Food and Drug Administration (FDA) indication (or an off label 
medically accepted use) for Vyvgart for myasthenia gravis without anti-acetylcholine receptor antibodies. The 
clinical value and effectiveness of Vyvgart in the setting of seronegative myasthenia gravis have not been 
demonstrated in the peer-reviewed literature. The review has determined that the documentation does not 
support that the Vyvgart 400MG/20ML solution (CPT code J3590) is medically reasonable or necessary for the 
patient. The documentation does not support that the Vyvgart 400MG/20ML solution (CPT code J3590) is safe 
and effective for the patient. 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 pre-approve administration of the drug (CPT code 96365) and Vyvgart 400MG/20ML solution (CPT 
code J3590).