Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on February 24, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these services. 
 
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 physician services provided on February 24, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee on April 
5, 2020. 
 
You asked the Plan to pay for out of network durable medical equipment. 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 equipment at issue in this appeal. The Plan did 
not pre-approve out of network equipment. We found no exception that would require the Plan to pay this 
claim. Therefore, we decided that the Plan does not have to pay for durable medical equipment provided to the 
enrollee on April 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 21, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
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 the laboratory services 
rendered on May 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on October 29, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the member's primary care physician. 
 
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 skilled nursing services provided on October 29, 
2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-rays provided on June 20, 2019. 
 
You asked the Plan to pay for the knee x-rays (73562). You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says from the information received they cannot determine how the enrollee came 
to the servicing provider or whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medical records were requested but not submitted to the Plan 
therefore medical necessity is not supported. Based on this information, we decided that Medicare rules for 
coverage of the knee x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the 
knee x-rays provided on June 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99152) provided December 10, 
2019. You asked the Plan to pay for moderate sedation services. You say that please see on page 2 that Fentanyl and 
Versed is used for sedation x80 minutes. Review and process for payment. The Plan denied your request. The 
Plan says there is insufficient documentation to corroborate the services to confirm Medicare coverage has 
been met. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. Based on this information, we decided that Medicare rules for 
coverage of moderate sedation services have not been met. Therefore, we decided that the Plan does not have 
to pay for moderate sedation services (99152) provided December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 21, 2020 to May 
20, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
provider or the facility. 
 
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 nursing facility care provided on January 21, 2020 
to May 20, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 21, 
2020. 
 
You asked the Plan to pay for the services. You say that these medical services are within the confines of 
prevailing medical practices and standards. The Plan denied your request. The Plan says this was not billed 
correctly. 
 
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 denied codes are not supported in the medical record. Specifically, this claim was billed with 
an inpatient place of service. Therefore, the denied lab services are included in the payment to the inpatient 
facility. 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 laboratory services provided to the enrollee 
on February 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the walker purchased on March 27, 2020. 
 
You asked the Plan to reimburse you for the walker. You say that you checked the Plan's website for approved 
vendors but no durable medical supplies are listed. The Plan denied your request. The Plan says the walker was 
obtained from a provider who is not under contract with the Plan and is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items provided directly by a provider who is not eligible to take Medicare payment.   
 
Payment cannot be made for items purchased from this provider because this provider is not a medical provider 
and is not enrolled in Medicare. Therefore, we decided that the Plan does not have to reimburse you for the 
walker purchased on March 27, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the total electric hospital bed provided from October 16, 2019 to May 
16, 2020. 
 
You asked the Plan to pay for the total electric hospital bed. You say that the rehab facility ordered the bed 
provided by the contracted provider. The Plan denied your request. The Plan says that a total electric hospital 
bed is not covered by Medicare because the height adjustment feature is a convenience feature. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the total electric hospital bed by a contract provider. The file does not show that the Plan 
provided notice that the total electric hospital bed would not be covered. Under Medicare rules, this means the 
total electric hospital bed is considered approved by the Plan. Therefore, we decided that the Plan has to pay for 
the total electric hospital bed provided from October 16, 2019 to May 16, 2020.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgery provided on February 23, 2020. 
 
You asked the Plan to pay for the osseous surgery. You say that an authorization was requested for this service, 
but you were not given an answer. You also say that you proceeded with the service because you had swollen 
gums. The Plan denied your request. The Plan says this service is not covered by the 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 
osseous surgery provided on February 23, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an ultrasound provided by a participating 
provider on February 28, 2020. 
 
You asked the Plan to waive the deductible for an ultrasound. You say that you do not agree with this 
deductible. The Plan denied your request. The Plan says the correct deductible has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible for outpatient diagnostic tests/in-network.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests/in-network. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $750 deductible for outpatient diagnostic tests/in-network. This cost sharing is a contractual 
obligation that had not been met at the time an ultrasound was received on February 28, 2020. The total amount 
you are being asked to pay is $194.52. Therefore, we decided that the Plan does not have to waive the 
deductible for an ultrasound provided by a participating provider on February 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient surgery you had on 
November 21, 2019. You asked the Plan to waive the coinsurance for the outpatient surgery. You say that you have been going to this facility for years and they were always in-network. The Plan denied your request. The Plan says you were 
charged this coinsurance correctly.  The Plan has confirmed that the facility where you had these services did 
not become a network facility until December 15, 2019, so they were out-of-network on your date of service.  
In addition, the Plan confirmed that all of your previous claims with this provider were processed as out-of-
network as well. 
 
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 40% 
coinsurance for Medicare-covered surgery or other services you receive at an out-of-network facility.  
 
You have been asked to pay 40% coinsurance for the outpatient surgery at an out-of-network facility. 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 outpatient surgery you had on November 21, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 14, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on December 14, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic screening testing provided on February 18, 2020. 
 
You asked the Plan to pay for genetic tests. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because this testing was 
performed for screening purposes which is not a Medicare benefit. 
 
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 tests at issue in this appeal, genetic tests, were requested for screening purposes. Medicare does not cover 
these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic 
screening testing provided on February 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration (20939). 
 
You asked the Plan to pre-approve bone marrow aspiration. 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 bone marrow aspiration. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of bone marrow aspiration in conjunction with the lumbar surgery 
performed. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of 
bone marrow aspirate for this enrollee's medical condition. Therefore, the request for bone marrow aspirate is 
not medically reasonable and necessary for the approved lumbar fusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspiration (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day reader. You asked the Plan to pre-approve a Freestyle Libre 14 day reader. 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 CGM devices are covered when specific criteria is 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 Freestyle Libre 14 day reader. Our reviewer says that the item is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that you meet the coverage criteria. There is no documentation that you are performing frequent (four or more times a day) finger stick glucose testing. 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 The Plan follows Medicare rules. Medicare rules say that CGM devices are covered when specific criteria is 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 Freestyle Libre 14 day reader. Our reviewer says that the item is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that you meet the coverage criteria. There is no documentation that you are performing frequent (four or more times a day) finger stick glucose testing. 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 Freestyle Libre 14 day reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day reader.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve functional electrical stimulator, transcutaneous 
stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified (E0770). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been 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 the DME. Our physician reviewer 
found the documentation does not support the medical necessity of the functional electrical stimulator, 
transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified 
(E0770) per Medicare's NCD. The documentation does not reveal that the device is being used for walking in a 
patient  with a Spinal Cord Injury (SCI) or that this device is being used for disuse atrophy where nerve supply 
to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons 
for disuse atrophy. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any 
type, complete system, not otherwise specified (E0770).