Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on March 24, 
2020. 
 
You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were not pre-approved or emergent. 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 has network providers 
available who can provide 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 the psychotherapy services (90832) provided on March 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable x-ray services (R0075, Q0092) provided on July 
3, 2019. 
 
You asked the Plan to pay for the portable x-ray services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were not pre-authorized or emergent. 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 has network providers 
available who can provide 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 the portable x-ray services (R0075, Q0092) provided on July 3, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on August 
7, 2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the 
documentation did not include a valid physician order/lab requisition form or medical records signed by the 
ordering physician to provide exactly what tests were to be performed. Based on this information, we decided 
that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing coded 80307 and G0483 provided on August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) and a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on March 12, 2020.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) and a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on March 12, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the rest home visit (99337). You say that you would like reconsideration because the provider relies on the hospital staff to verify eligibility and obtain the proper authorization. The Plan denied your request. The Plan says utilization of network providers is required when possible and 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 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 October 29, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on March 11, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 
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 physician's services provided on March 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 17, 2020.
You asked the Plan to pay for the laboratory services. 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.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, the physician must clearly document, in the medical record, his or her intent that the test be
performed.
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services provided on February 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for cerebral perfusion analysis (0042T) provided February 10, 2020.
You asked the Plan to pay for cerebral perfusion analysis. You say that the procedure was medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that cerebral perfusion analysis is not covered. We looked at the file and Medicare rules. The service at issue is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of cerebral perfusion analysis have not been met. Therefore, we decided that the Plan does not have to pay for cerebral perfusion analysis (0042T) provided February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 25, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 provided on November 25, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided from January 2, 2020 to February 19, 2020.
You asked the Plan to pay for service from this provider. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says neither Medicare nor the Plan can pay claims to providers who have opted out of the Medicare program.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program. This provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for physician services provided from January 2, 2020 to February 19, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 skilled nursing visits, 13 physical therapy (PT) visits, 
3 occupational therapy (OT) visits, and 13 home health aide visits. 
 
You asked the Plan to pre-approve 20 skilled nursing visits, 13 PT visits, 3 OT visits, and 13 home health aide 
visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 20 skilled nursing visits, 13 PT visits, 3 
OT visits, and 13 home health aide visits. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the records do not show that skilled nursing services are required to effectively 
provide treatment, care, and/or services in order to improve your condition, to establish/perform a maintenance 
program to maintain your condition and/or prevent deterioration. Your wound care is not complex and there are 
no signs of infection. You have had education on equipment and your medical condition. Your medical 
conditions are chronic and stable. The records do not indicate that ongoing skilled therapy services are required 
to effectively provide treatment, care, and/or services in order to improve your level of function, or to 
establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. Your 
functional status does not require ongoing PT or OT. You have not made significant objective changes in 
function despite extensive therapy and your current functional status does not require the ongoing skills of a 
professional therapist for PT or OT. Without the need for skilled nursing or skilled therapy you do not meet the 
definition of home health aide services as per Section 50.2 and home health aide services are not reasonable 
and necessary to the treatment of your illness or injury by the skilled professional staff. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 20 skilled nursing visits, 13 PT visits, 3 OT visits, and 13 home health aide 
visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 20 skilled nursing 
visits, 13 physical therapy (PT) visits, 3 occupational therapy (OT) visits, and 13 home health aide visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulpal debridement (D3221) provided on February 26, 
2020. 
 
You asked the Plan to pay for the pulpal debridement. You say that a Plan representative informed you that this 
Plan covers all dental work, including root canal. The Plan denied your request. The Plan says this service is 
not covered by your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pulpal 
debridement (D3221) provided on February 26, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99309) provided March 13, 2020. 
 
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not emergent or pre-authorized. In-network providers 
were 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 has network providers 
available who can provide 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 nursing facility care (99309) provided March 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on July 9, 2019. 
 
You asked the Plan to pay for the drug panel. You say that this is medically necessary testing. The Plan denied 
your request. The Plan says the order form for this testing is not signed by the treating provider and no medical 
records were submitted to support the intent for this testing to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the 
treating physician. Orders need not be signed but the record must document the intent to perform the testing.  
 
The order form is not signed by the provider. No records documenting the intent to perform this testing were 
submitted. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on 
July 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have 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 coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PET scans are covered for a differential diagnosis of 
fronto-temporal dementia (FTD) and Alzheimer's disease (AD). 
 
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 PET scan is not medically necessary. Our physician reviewer found the records only suggest the possibility 
of Alzheimer's Disease. There's no records to support the need for a differential diagnosis. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Positron Emission Tomography (PET) scan (78608).
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 
from January 13, 2020 to February 3, 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 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 out of network physician services provided to the enrollee from January 13, 2020 to 
February 3, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99285, 71046)
provided March 24, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should
be waived because you were unable to get the services at a walk-in clinic due to COVID-19 concerns. The Plan
denied your request. The Plan says the correct copayment was applied for the services that were rendered.
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 $90
copayment for Emergency Care.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
within the Emergency Care 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 an
emergency room visit (99285, 71046) provided March 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 9, 2019. 
 
You asked the Plan to pay for the laboratory services. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician?s intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on October 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Promethazine Sup 25mg.
You asked the Plan to pre-approve Promethazine Sup 25mg. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Promethazine Sup 25mg.
Benefits for Promethazine Sup 25mg 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for power seat elevation system (E2300) and manual 
swingaway, retractable or removable mounting hardware for joystick (E1028) provided August 2, 2019. 
 
You asked the Plan to pay for the wheelchair accessories. You say that you sent in documentation to the 
authorization department prior to providing the equipment and all but one item was approved. Please process 
this claim for payment. The Plan denied your request. The Plan says E2300 does not serve a medical purpose 
and is not covered by Medicare and E1028 denied that this item has already processed. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for power seat elevation system (E2300) and manual swingaway, 
retractable or removable mounting hardware for joystick (E1028) provided August 2, 2019.