Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home therapy, enteral nutrition via pump provided March 1, 
2020 to March 31, 2020. 
 
You asked the Plan to pay for home therapy, enteral nutrition via pump. You say that S9342 is a valid code to 
bill. The plan paid the month before for the same exact code on date of service 2/01/2020 showing this is a 
valid code. Please review this claim again to reprocess. The Plan denied your request. The Plan says Medicare 
guidance says status code I is not valid for Medicare purposes. Medicare uses another code for reporting of, 
and payment for these services. 
 
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 S9342 is Home therapy; enteral nutrition via pump; 
administrative services, professional pharmacy services, care coordination, and all necessary supplies and 
equipment (enteral formula and nursing visits coded separately), per diem. 
 
We find that CPT code S9342 is not supported in the medical record. Specifically, CPT code S9342 has a status 
code of I. Per the Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and Coding 
Requirements, Section 30.2.2 - MPFSDB Status Indicators, ?I? is Not valid for Medicare purposes. Medicare 
uses another code for reporting of, and payment for, these services. Based on this information, we decided that 
Medicare rules for coverage of home therapy, enteral nutrition via pump have not been met. Therefore, we 
decided that the Plan does not have to pay for home therapy, enteral nutrition via pump provided March 1, 
2020 to March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for podiatry services provided on January 2, 
2020, to January 30, 2020. 
 
You asked the Plan to waive the deductible for podiatry services. You say that you were not aware that the 
provider was out-of-network. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
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 out-of-network services. Your contract with the 
plan also clearly says that after the $750 deductible has been met, enrollee's must pay a $40 copayment for 
podiatry services. 
 
You received podiatry services from an out-of-network provider on January 2, 2020. The record shows that you 
had paid $0 toward the $750 deductible. Therefore, you are responsible to pay the total allowed amount of 
$115.80.  
 
You received podiatry services from an out-of-network provider on January 14, 2020. The record shows that 
you had paid $115.80 toward the $750 deductible. Therefore, you are responsible to pay the total allowed 
amount of $300.18. 
 
You received podiatry services from an out-of-network provider on January 30, 2020. Therefore, you are 
responsible to pay the $40 copayment. The total amount you owe is: $455.98.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category podiatry 
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible for out-of-network podiatry services. The Plan contract also says that after the $750 deductible has 
been met, enrollee's must pay a $40 copayment for podiatry services. This cost sharing is a contractual 
obligation that had not been met at the time podiatry services were received on January 2, 2020, to January 30, 
2020. Therefore, we decided that the Plan does not have to waive the deductible for podiatry services provided 
on January 2, 2020, to January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 15, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. 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 June 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray and motion fluoroscopic evaluation of swallowing 
function by cine or video recording services provided on July 3, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for these OON services. 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 payable. 
 
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 x-ray and motion fluoroscopic evaluation of 
swallowing function by cine or video recording services provided on July 3, 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 the nervous system surgery provided on February 26, 2020 
by an OON provider. 
 
You asked the Plan to pay for the nervous system surgery. You say that you feel that this service should be 
covered because it is a proven approach to relieve chronic groin pain following inguinal hernia repair. The Plan 
denied your request. The Plan says the services were rendered by a non-network provider, and the enrollee self-
directed for 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 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 nervous system surgery provided on February 
26, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost sharing for the transthoracic echocardiography 
provided on July 8, 2020. 
 
You asked the Plan to adjust the cost sharing for the transthoracic echocardiography. You say that the 
copayment should only be $50 for the transthoracic echocardiography. The Plan denied your request. The Plan 
says you were charged the coinsurance 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 20% 
coinsurance for Diagnostic Imaging.  
 
You have been asked to pay a 20% coinsurance for the transthoracic echocardiography. The transthoracic 
echocardiography falls within the Diagnostic Imaging 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 adjust the 
cost sharing for the transthoracic echocardiography provided on July 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve a manual wheelchair. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that manual wheelchairs are only covered for certain 
indications. 
 
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 manual wheelchair. Our reviewer says 
that the documentation does not support that the requested manual wheelchair is medically reasonable or 
necessary. Our physician reviewer found the enrollee has a past medical history of hypertension, rheumatoid 
arthritis, colon cancer and a left humerus fracture from December 1, 2019 and is reported to have difficulty 
ambulating. There is no documentation in the records that the enrollee has a mobility limitation that 
significantly impairs her ability to participate in one or more mobility-related activities of daily living such as 
toileting, feeding, dressing, grooming, and bathing in customary locations in the home. Therefore, the enrollee 
does not meet criteria for the requested wheelchair. 
 
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 manual wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a manual wheelchair.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for Tumor Marker Panel Testing provided on April 23, 2020. 
 
You asked the Plan to pay for the laboratory services (81206, 81275, 81210, 81235). You say that the Plan 
should pay this claim. The Plan denied your request. The Plan says there is no documentation of the enrollee's 
stage of cancer which is required per policy. 
 
The Plan must follow Medicare rules. The rules say that documentation must be adequate to verify that 
coverage guidelines listed above have been met. 
 
There is no documentation of the enrollee's stage of cancer. Therefore, we decided that the Plan does not have 
to pay for Tumor Marker Panel Testing provided on April 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to pay for the telephone evaluation and management service provided 
on May 12, 2020 by an OON provider. 
 
You asked the Plan to pay for the telephone evaluation and management service. You say that you could not 
see your primary care physician for treatment due to COVID-19. You also say that this provider was able to 
assist you with medication changes and medication management via telehealth. The Plan denied your request. 
The Plan says the service was rendered by a non-network provider. The Plan also says that the service was not 
urgent or emergent, and were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the telephone evaluation and management service 
provided on May 12, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the oral evaluation (D0120), prophylaxis 
(D1110), bitewing x-rays (D0274), and the unspecified preventive dental service (D1999) provided on June 24, 
2020. 
 
You asked the Plan to pay the in network rate for the dental services. You say that you have been seeing this 
provider for a few years. You say that the provider did not advise they were no longer takes your insurance. 
You also say that you would not knowingly see a provider that was out of network. The Plan denied your 
request. The Plan says the dental provider in this case is not a network provider. The Plan says that care 
rendered by a provider that is not part of our supplemental dental network is not covered. 
 
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 dental services you received are not 
covered when rendered by a provider that is not part of the supplemental dental network. Therefore, we decided 
that the Plan does not have to pay the in network rate for the oral evaluation (D0120), prophylaxis (D1110), 
bitewing x-rays (D0274), and the unspecified preventive dental service (D1999) provided on June 24, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you 
received from March 1, 2020, to March 23, 2020. 
 
You asked the Plan to waive the copayment for the SNF services. You say that you told the staff at the SNF 
that you were to be released before a copayment would apply.  You also say that you think the reason why your 
request was ignored was due to COVID-19. 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 $0 
copayment per day for days 1-20, and a $160 copayment per day for days 21-54 for skilled nursing facility 
care.  
 
Records show that you were admitted to the SNF on February 23, 2020 and you were discharged on March 23, 
2020.  This means that your stay was a total of 29 days.  In accordance with your Evidence of Coverage, you 
were not charged a copayment for days 1-20.  Starting on February 14, 2020, you were charged a $160 
copayment per day for the remaining 9 days of your stay, for a total copayment obligation of $1,440. This is the 
exact amount you are being charged, so your copayment obligation was calculated correctly.  This copayment 
applies regardless of the reason for the length of your stay. 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 skilled nursing facility (SNF) services you received from March 1, 2020, to March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 22, 2020 to March 31, 2020. 
 
You asked the Plan to pay for home health services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the RAP claim was not billed and the billed claim was not a No-RAP 
LUPA. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the provider 
is a non-contract provider for the enrollee's health plan and a valid RAP claim was not submitted prior to the 
final claim for processing. Therefore, we decided that the Plan does not have to pay for the home health 
services provided to the enrollee from February 22, 2020 to March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laser therapy (S8948, photobiomodulation therapy) and a 
computed tomography (CT) scan provided on March 17, 2020, out of network. 
 
You asked the Plan to pay for laser therapy and a CT scan provided out of network. You say that you do not 
believe this bill is correct. The Plan denied your request. The Plan says the laser therapy provided was for 
treatment of TMJ which is not covered by Medicare. The Plan indicates the CT scan was covered however the 
cost was applied to your $1500 yearly deductible. 
 
The Plan must follow Medicare rules. Medicare does not cover services provided for the treatment of TMJ. 
Therefore, the Plan is not required to pay for the laser therapy provided for this type of treatment. Your contract 
with the Plan says that there is $1500 deductible that must be paid prior to Plan participating in the cost of your 
covered services. This cost sharing is a contractual obligation that had not been met at the time the CT scan was 
provided.  
 
Therefore, we decided that the Plan does not have to pay for laser therapy (S8948, photobiomodulation 
therapy) and a computed tomography (CT) scan provided on March 17, 2020, out of network.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 13, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you fell and could not get up. The fireman 
assisted you and did not request the ambulance service. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 13, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 13, 
2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biofeedback provided on May 19, 2020. 
 
You asked the Plan to pay for biofeedback. You say that you do not believe these bills are correct. The Plan 
denied your request. The Plan says the Plan contract clearly states biofeedback is not covered. 
 
The Plan follows Medicare rules. The rules say that Medicare does not cover investigational services. 
Biofeedback is covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for 
biofeedback provided on May 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
October 29, 2019. 
 
You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare and was 
medically necessary. The Plan denied your request. The Plan says the denial of payment for this testing is 
correct, because this testing was not billed with the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service October 29, 2019.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
October 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided on May 27, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because the x-ray 
was medically necessary and ordered by the member's referring physician. The Plan denied your request. The 
Plan says in patients at risk for developing lung cancer, screening for lung cancer with chest x-rays, once or at 
regular intervals, is not recommended. 
 
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 test at issue in this appeal, the chest x-ray, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for a 
chest x-ray (71045) provided on May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bilateral Sacroiliac Radiofrequency Ablation. 
 
You asked the Plan to pre-approve Bilateral Sacroiliac Radiofrequency Ablation. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that bilateral sacroiliac radiofrequency ablation is covered 
for certain indications. 
 
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 Bilateral Sacroiliac Radiofrequency 
Ablation. Our reviewer says that the documentation does not support that the requested services are medically 
reasonable or necessary. Our physician reviewer found you have a history of low back pain related to 
sacroiliitis. The pain radiates to the buttocks. You have received previous sacroiliac joint injections.  

Radiofrequency ablation used for sacro-iliac joint pain is considered not medically necessary/investigational 
whether performed using traditional, cooled, or pulsed radiofrequency. The documentation does not support 
that you have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of Bilateral 
Sacroiliac Radiofrequency Ablation. Therefore, you do not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Bilateral Sacroiliac Radiofrequency Ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Bilateral Sacroiliac Radiofrequency Ablation.