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

 
We decided that the Plan does not have to pay for the normal saline solution used during a chemotherapy 
treatment. 
 
You asked the Plan to pay for the saline solution. You say that this service should be paid. The Plan denied 
your request. The Plan says these services were approved for payment aside from the use of saline which is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of saline for drug infusions is considered 
incidental hydration and is not separately paid. Therefore, we decided that the Plan does not have to pay for the 
normal saline solution used during a chemotherapy treatment.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on November 26, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this testing was ordered for screening purposes. In addition, the Place of Services codes 
on the claim were not correct for the services billed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. The rules state the claims must be submitted with the correct POS code.  

The test at issue in this appeal, was requested solely for screening purposes. The claim submitted has technical 
errors as well preventing payment. Medicare payment criteria are not met. Therefore, we decided that the Plan 
does not have to pay for lab services provided to the enrollee on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
August 6, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 has network providers available who can provide 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 out of network physician 
services provided to the enrollee on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for emergency room (ER) visits you had on 
June 6, 2020, and June 17, 2020. 
 
You asked the Plan to waive the copayments for the ER visits. You say that you shouldn't have to pay these 
copayments because the services you received didn't do you any good. The Plan denied your request. The Plan 
says you were charged these copayments 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 per visit for emergency care.  
 
You have been asked to pay a $100 copayment per visit for the ER visits. These copayments apply regardless 
of your satisfaction with the services received. 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 copayments for emergency 
room (ER) visits you had on June 6, 2020, and June 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided thatthe Plan does not have to pay forlab services provided to the enrollee on August 28, 2019 and billed under codes 81225, 81226, 8122781230, 81231, 8123281240, 81241, 8128381291, 81328, 81335, 81350, 81355, 81479.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says that this claim cannot be paid as billed due to coding errors. The Plan says asComprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX; and it is a test not currently satisfactorily described by any existing CPT code; to report a CGP, service providers should use CPT code 81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes.If CPT 81479 is also on the claim as an unlisted unbundled item, it does not meet the Medicare prescribed use for the bundled code. Coverage of CGP is limited toone test per specimen and precludes the use of any other molecular testing on the specimen.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the claim submitted cannot be paid as billed due to coding errors. The Plan states a corrected claim would be reviewed if submitted. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay forlab services provided to the enrollee on August 28, 2019 and billed under codes 81225, 81226, 8122781230, 81231, 8123281240, 81241, 8128381291, 81328, 81335, 81350, 81355, 81479.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 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 kyphoplasty. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found criteria for kyphoplasty has not met. There is no documentation of severe disabling pain. More 
information about symptoms is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on June 25, 2020. 
 
You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied 
your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 has network providers available who can provide 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 physician services provided 
to the enrollee on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 49000 defined as exploratory laparotomy, exploratory 
celiotomy with or without biopsy(s) (separate procedure), provided to the enrollee on August 28, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the records provided do not support the services billed. 
 
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 this service. Our reviewer says that 
Medicare criteria are not met. Our physician reviewer found the records show the enrollee received services on 
August 28, 2019 for Common Procedural Terminology (CPT) 49000 - exploratory laparotomy, exploratory 
celiotomy with or without biopsy(s) (separate procedure).  The documentation submitted was reviewed. The   
procedure documents insertion of a jejunostomy tube, no documentation of exploratory celiotomy with or 
without biopsy was performed.  Medicare billing criteria are not met. We looked at this physician's review, the 
file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service 
have not been met. Therefore, we decided that the Plan does not have to pay for code 49000 defined as 
exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure), provided to the 
enrollee on August 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 18, 2020 to May 25, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the durable medical equipment (L1812, E0244). You say that you require these 
items. The Plan denied your request. The Plan says this is not a provider that participates with 
Medicare program. 
 
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 has network providers 
available who can provide 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 medical services provided on May 18, 2020 to 
May 25, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunizations provided to the enrollee on May 28, 2020. 
 
You asked the Plan to pay for immunizations under Medicare Part B. You say that this claim should be paid. 
The Plan denied your request. The Plan says the immunizations provided are not covered under Medicare Part 
B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunizations 
under Medicare Part B. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to immunizations 
under Medicare Part B. Therefore, we decided that the Plan does not have to pay for immunizations provided to 
the enrollee on May 28, 2020.  
 
Benefits for immunizations under Medicare Part B may be available under Medicare Part D. Contact the Plan 
that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided to the enrollee on July 14, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization which is required both in and out of 
network. 
 
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 has network providers available who can provide 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 genetic testing provided to 
the enrollee on July 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapy services provided March 13, 2020. 
 
You asked the Plan to pay for the outpatient therapy services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the provider is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the services at issue are not supported. Specifically, the record shows the provider was not 
enrolled in Medicare at the time services were rendered. Based on this information, we decided that Medicare 
rules for coverage of the outpatient therapy services have not been met. Therefore, we decided that the Plan 
does not have to pay for outpatient therapy services provided March 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.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 the patient appears to be improving, but still requires additional short term acute care services of less than 25 days to further stabilize and ensure completion of treatment which can be safely completed at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may soon be considered when treatment has completed.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approveLTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services (15275, Q4196) provided by an 
out of network (OON) provider. 
 
You asked the Plan to pay for OON wound care services. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide 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 wound care services (15275, Q4196) provided 
by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON home health services. You say that the enrollee previously used this 
provider. The Plan denied your request. The Plan says the requested services are available in-network. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the home 
health services 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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee had 3 strokes and is a double amputee. 
You say that the enrollee needs acute care and rehab. The Plan denied your request. The Plan says the enrollee's 
needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that it is not reasonable to expect that the enrollee will be able to fully benefit from 
the intensity of services of an IRF. Our reviewer says that services can safely be received in other settings. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee requires the device. 
The Plan denied your request. The Plan says the documentation failed to prove that sufficient evidence of four-
week trial of conservative therapy. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. A four-week 
trial of conservative therapy demonstrating failed response to treatment is required. 
 
 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular home usage of conservative therapy including compression garments, exercise and 
elevation. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gym benefits provided.  
 
You asked the Plan to pay for gym benefits. You say that the Plan should pay for these benefits. The Plan 
denied your request. The Plan says this provider does not participate in the Renew Active fitness network.  
 
Medicare does not cover gym benefits. The Plan only covers gym benefits from facilities that participate in the 
Renew Active fitness network. The provider in question is not in that network. Therefore, we decided that the 
Plan does not have to pay for gym benefits.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the deductible for the ophthalmological services (92014, 92226) 
provided on December 13, 2019. 
 
You asked the Plan to waive the deductible for the ophthalmological services. You say that you had already 
met your deductible before the date of service on December 13, 2020. The Plan denied your request. The Plan 
says that the deductible and remaining coinsurance applied correctly in this case. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. You have included the Explanation of Benefits (EOB) in your appeal request 
stating that your deductible had already been fully met before the date of service on December 13, 2019. The 
Plan has failed to provide evidence that would adequately refute this EOB submitted. Therefore, we decided 
that the Plan has to waive the deductible for the ophthalmological services (92014, 92226) provided on 
December 13, 2019.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Positron Emission Tomography (PET) scan (78608). 
 
You asked the Plan to pre-approve the PET scan. You say that The PET scan is medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 PET scan. Our reviewer says that 
the requested PET scan is medically necessary. Our physician reviewer found a PET scan is indicated for the 
enrollee's diagnosis. Medical records support that the PET scan requested is medically 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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a Positron Emission Tomography (PET) scan (78608).  
 
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.