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

 
We decided that the Plan does not have to reduce the copayment for the ultrasound provided on December 15, 
2022. 
 
You asked the Plan to reduce the copayment for the ultrasound. You say that you should have a $20 
copayment. 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 $25 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $25 copayment for the ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The record shows you are being charged for an ultrasound not an 
office visit. Therefore, we decided that the Plan does not have to reduce the copayment for the ultrasound 
provided on December 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital stay provided on October 20, 2022, to 
October 27, 2022. 
 
You asked the Plan to pay for inpatient hospital stay. You say that you are requesting the submitted 
documentation be reviewed. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for inpatient hospital stay 
provided on October 20, 2022, to October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure provided on August 17, 2022. 
 
You asked the Plan to pay for therapeutic procedure. You say that you are requesting the submitted 
documentation be reviewed. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for therapeutic procedure 
provided on August 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on November 30, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration for the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies to be 
provided by an OON provider. 
 
You asked the Plan to pre-approve a glucose monitor and supplies. You say that you are asking for 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the requested 
items are not covered by an out-of-network provider. 
 
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 Plan contract 
also says that the enrollees POS benefit does not apply to out-of-network durable medical equipment. 
 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 
a continuous glucose monitor and supplies to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the physical therapy services provided on 
December 19, 2022. 
 
You asked the Plan to waive the coinsurance for the physical therapy services. You say that you had already 
met your out-of-pocket maximum for the year. 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 15% coinsurance for in-network physical therapy.  
 
The records show the out-of-pocket maximum was processed correctly, and you are responsible for the cost 
share amount. You have been asked to pay 15% coinsurance for the physical therapy service. This item/service 
falls within the outpatient rehabilitation services 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 the physical therapy services provided on December 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy provided on November 01, 2022, to 
November 22, 2022. 
 
You asked the Plan to pay for occupational therapy. You say that you say that prior authorization is not 
required for Part B Services. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for occupational therapy 
provided on November 01, 2022, to November 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) shows facet degenerative joint disease (djd) 
and foraminal stenosis. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the cataract surgery provided on February 
14, 2023. 
 
You asked the Plan to reduce the copayment for the cataract surgery. You say that you were told there would 
not be a copayment greater than $45. 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 $270 
copayment for outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $270 copayment for the cataract surgery. This item/service falls within the outpatient surgery, including services provided at 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 reduce the copayment for the cataract surgery provided on February 14, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 16, 2021 to 
February 11, 2021. 
 
You asked the Plan to pay for the home health services as billed. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the claim has not been billed with 
the correct admission date. 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 16, 2021, to 
February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 17, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says that lab services are not covered when received by an out-of-network 
provider. 
 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 Plan contract also says that the enrollee's POS benefit does 
not apply to out-of-network lab services. 
 
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 laboratory services provided on August 17, 
2022, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oblique lateral lumbar interbody fusion (OLLIF). 
 
You asked the Plan to pre-approve an OLLIF. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 an OLLIF. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a spinal surgery itself is not supported as dynamic flexion/extension films are not provided in 
order to potentially assess the amount of movement (instability) at the requested surgical levels. Detailed 
documentation is not evident regarding potential impending/inevitable temporary intra-operative instability. No compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested L3-S1 OLLIF (oblique lateral lumbar interbody fusion), in 
this case, is 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 an OLLIF have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an oblique lateral lumbar interbody fusion (OLLIF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on October 11, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
services provided on October 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on October 18, 2022, to 
October 27, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you say that prior authorization is not 
required for Part B Services. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
care provided on October 18, 2022, to October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on January 05, 2023. 
 
You asked the Plan to pay for chiropractic care. You say that you are requesting reconsideration for the 
services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chiropractic care 
provided on January 05, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic interrogation of pacemaker 
 
You asked the Plan to waive the copayment for a diagnostic interrogation of pacemaker. You say that you were 
not aware it was being done on that day and there would be a copayment for it. The Plan denied your request. 
The Plan says you pay $20 per day for Medicare-covered outpatient diagnostic tests. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees must pay $20 copayment for outpatient diagnostic tests and therapeutic services and 
supplies. 
 
The enrollee has been asked to pay $20 copayment for a diagnostic interrogation of pacemaker. Diagnostic 
interrogation of pacemaker falls within the outpatient diagnostic tests and therapeutic services and supplies 
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic interrogation of 
pacemaker
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on October 10, 2022. 
 
You asked the Plan to pay for a new patient office visit. You say that you were told that this provider was in-
network. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a new patient office visit 
provided on October 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the PET scan the medical supplies provided 
on September 14, 2022. 
 
You asked the Plan to waive the cost share for the PET scan and the medical supplies. You say that you were 
not advised of the excessive copayment. 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 $100 
copayment for Medicare-covered radiological diagnostic services. Your contract with the Plan clearly says that 
you must pay 20% coinsurance for each Medicare-covered medical supply. 
 
You have been asked to pay a $100 copayment for the PET scan. You have also been asked to pay $1,395.17 
coinsurance, which is 20% of the allowed amount for the medical supplies ($6,975.85 allowed amount x 20% = 
$1,395.17). These items/services fall within the outpatient diagnostic tests and therapeutic services and supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the cost share for the PET scan the medical supplies 
provided on September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96374-59 and 96375-59 provided on June 
14, 2022. 
 You asked the Plan to pay for procedure codes 96374-59 and 96375-59. You say that the medical records 
support the use of modifier 59 billed with codes 96374 and 96375. The Plan denied your request. The Plan says 
the medical records do not support the use of modifier 59 billed with codes 96374 and 96375. 
 
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 codes 96374 and 96375 are column II codes to column I codes 64483 and 
99152; however, 96374 and 96375 were billed with a modifier.  
 
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 procedure codes 96374-59 and 96375-59. Our reviewer says 
that the medical records do not support the use of modifier 59 billed with codes 96374 and 96375. Our 
reviewer found the record does not support that any separately reportable IV injections were performed during 
this encounter. The medications administered were included in the main procedures. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 96374-59 and 96375-59 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 96374-59 and 96375-59 provided on June 14, 
2022.