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

 
We decided that the Plan does not have to pay for dermatology services (11102) provided on April 1, 2021. 
 
You asked the Plan to pay for the dermatology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says there were network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for dermatology services (11102) provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient clinic visit and laboratory services provided by 
an out-of-network provider on October 8, 2021. 
 
You asked the Plan to pay for the outpatient clinic visit and laboratory services. You say that the medical 
records support the medical necessity of the services that were provided to the member in good faith. You say 
that you are requesting payment for the claim. The Plan denied your request. The Plan says procedure code 
82728 was not billed with an appropriate diagnosis code. The Plan also says that the remaining services are 
denied because this provider is not a network provider and out-of-network services 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 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 clinic visit and laboratory services 
provided by an out-of-network provider on October 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  
February 10, 2021, through February 12, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the 
inpatient admission was not medically necessary. 
 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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee is a 74-year-old female who presented to the emergency department 
with dizziness, headache, chest tightness having failed Zofran 8 mg. The enrollee had right eye nystagmus with 
sitting up, pitting edema legs and ataxia. A computerized tomography (CT) of the head was negative. On 
admission, the enrollees headache was mostly resolved. Vertigo diagnosed with suspicion for central etiology. 
The enrollee was given meclizine which helped, and she had no focal weakness, no nystagmus. A Magnetic 
resonance imaging was negative. Physical therapy was recommended. Based on the provided notes, the 
enrollees workup and treatment response early on showed that she was stable and there was no suggestion that 
the enrollee would require hospital services that would likely cross 2 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 pay for the acute inpatient hospital care provided from February 10, 2021, through 
February 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (88305, 88312) provided on June 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that this claim was denied incorrectly. The Plan denied 
your request. The Plan says the payment for these services is included in the hospital's contract rate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the documentation supports that the member was a hospital outpatient on the billed date of service. 
The technical component for these services is paid to the facility and is the responsibility of the facility to any 
vendor. These services have not been billed with the appropriate modifier to indicate that only one component 
is being billed. 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 the lab services (88305, 88312) 
provided on June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have pain in the arch of your foot both day 
and night. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital outpatient clinic visit to be rendered by the 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested 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 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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a hospital 
outpatient clinic visit to be rendered by the out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician office visit (99215, G2212) and monitored drug 
administration (J3490) provided on September 10, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for a physician office visit and monitored drug administration. You say that the 
services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules 
for payment for out-of-network care 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 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 physician office 
visit (99215, G2212) and monitored drug administration (J3490) provided on September 10, 2021, by an out-
of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
19, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70450 is bundled into payment for 70496.  
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 19, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 5, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70450 is bundled into payment for 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
March 18, 2021, to March 24, 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 provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The provider started billing inpatient services on March 18, 2021, which is four days before the enrollee was 
actually admitted inpatient on March 22, 2021. It is allowed to bill inpatient for three days of pre-admission 
services. 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 inpatient hospital services provided to the 
enrollee from March 18, 2021, to March 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and the arthrocentesis, aspiration 
and/or injection, of a major joint or bursa, without ultrasound guidance (20610) rendered by the out-of-network 
(OON) provider on July 8, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99213) and the arthrocentesis, aspiration and/or injection, of a 
major joint or bursa, without ultrasound guidance (20610) rendered by the out-of-network (OON) provider on 
July 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 20, 2021. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says the provider 
didnt bill the required modifier to show the service was unrelated to the hospice condition. Without the 
modifier, the claim is considered payable by the hospice benefit and not Medicare or the Medicare Advantage 
Plan. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on October 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 2. 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70450 is bundled into payment for 70496.  
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service December 2. 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 25, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70450 is bundled into payment for 70496.  
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service August 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service November 
22, 2021. 
 
You asked the Plan to pay for procedure code 71045. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 71045 is bundled into payment for 71046.  
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 71046. 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 71045 billed for date of service November 22, 
2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy service (90832) rendered by the out-of-
network (OON) provider on November 17, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal.  The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for 
this service. Therefore, we decided that the Plan does not have to pay for the psychotherapy service (90832) 
rendered by the out-of-network (OON) provider on November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the enrollee continues to have persistent pain 
radiating down the leg. The Plan denied your request. The Plan says the enrollee did not have sustained relief 
with previous injections in the same region. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee did not have sustained pain relief of more than 50% with the previous transforaminal 
epidural steroid injections (TFESIs). Additional TFESIs for more than two level are requested. The review has 
determined that the repeat injections are not indicated for the enrollee's condition. The services are not 
medically reasonable or necessary. 
 
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 an epidural steroid injection (ESI) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 22, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. 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 each visit with a specialist.  
 
The file shows that the provider billed the visit as a primary care visit instead of a specialist. Therefore, you 
have been asked to pay $10, which is less than the $45 copayment for the specialist office visit. The specialist 
office visit falls 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 copayment for a specialist office visit provided on November 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on June 15, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the ambulance 
refused to take you to the hospital you requested. The Plan denied your request. The Plan says per Medicare 
guidelines, the ambulance benefit is a transport benefit. If there is no transport, then there is no Medicare-
covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 15, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. 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 follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
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 a spinal cord stimulator. Our reviewer 
says that the services are not medically necessary.  Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures. The documentation does not support 
a trial and failure of spinal injections (including but not limited to epidural steroid injections or medial branch 
blocks.) Furthermore, detailed documentation is not evident regarding a surgical consult that indicated surgery 
was not appropriate. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception to guidelines. Therefore, the enrollee does not meet the 
coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.