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

We decided that the Plan does not have to pay for molecular testing provided to the enrollee on May 20, 2020. 
 
You asked the Plan to pay for this service. You say that this testing should be covered by the Plan. The Plan 
denied your request. The Plan says the records do not demonstrate that this testing was medically necessary. 
 
Medicare rules say that plans can require enrollees to get prior authorization. The Plan contract says that 
outpatient lab services, which would include diagnostic molecular testing, required prior authorization. The 
records provided do not show this testing was granted prior authorization nor that it was medically necessary. 
Medicare coverage criteria and Plan contract criteria are not met. Therefore, we decided that the Plan does not 
have to pay for molecular testing provided to the enrollee on May 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) services coded 
70544 provided on August 10, 2020. 
 
You asked the Plan to pay for the MRA 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 separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70544 
for the MRA services has a bundled relationship with code 70551 and cannot be paid as billed. This code 
cannot be paid as a separate line item.  

Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for the magnetic resonance angiography (MRA) services coded 70544 provided on 
August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the patient lift (E0630) and trapeze bars (E0910) provided on 
May 10, 2020, through June 9, 2020. 
 
You asked the Plan to pay for the patient lift and trapeze bars. You say that you would like reconsideration 
because this equipment is medically necessary. The Plan denied your request. The Plan says the documentation 
submitted did not include a valid physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the patient lift (E0630) and trapeze bars (E0910) provided on 
May 10, 2020, through June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient consultation rendered on October 2, 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 procedure code 99254 is not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes. 
 
We looked at the file and Medicare rules. The provider billed code 99254. This code has a status indicator of I 
and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the 
inpatient consultation rendered on October 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided to the enrollee on August 14, 
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 claim was not submitted with a valid physician order or medical records that the 
support the services billed. The Plan also stated an inappropriate POS code was reported on the claim. 

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and medical records to support the services billed. 
The claim submitted does not have a valid order. The claim does not have an appropriate POS code.  
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing (G0483) provided to the enrollee on August 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was seen in an outpatient setting for 
weakness and a home health evaluation was ordered. The enrollee's medical problems are stable. There are no 
identified problems that need inpatient medical management. There are no complex nursing or rehabilitation 
needs. The patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for 
physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF care. 

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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on 
January 28, 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 lab services 
provided to the enrollee on January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown on 
tooth # 2 (D2954). 
 
You asked the Plan to pre-approve dental code D2954. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are 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 requested prefabricated post and 
core in addition to crown with dental code D2954 is not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown on tooth # 
2 (D2954).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement provided on July 28, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the debridement (11042). You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says you did not request 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 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 debridement provided on July 28, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services provided on September 25, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
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 September 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walker with seat attachment rendered on May 7, 2020. 
 
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. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that these services was used in a SNF. Medicare does not cover this equipment for use while in 
the SNF. Therefore, we decided that the Plan does not have to pay for the walker with seat attachment rendered 
on May 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary. The Plan 
denied your request. The Plan says that you do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM) and supplies.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient home visit (99349) provided on July 
17, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient home visit. 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 provider; therefore, payment has been correctly denied. 
 
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 established patient home visit (99349) 
provided on July 17, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections (CPT Codes: 64493, 64494, and 64495). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the records do not show that the member has had this type of pain for at least three (3) 
months. 
 
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 services. physician reviewer found 
the criteria are not met. The records do not show pain symptoms for at least three (3) months. The injections 
are not 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet injections (CPT Codes: 64493, 64494, and 64495).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from July 21, 2020, to 
July 22, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you should not be charged for the self-
administered drugs. You say that you brought your own medications and insulin with you to the hospital. You 
also say that you forgot to give your medications and insulin to the nurse once you got there and now you are 
being billed for them. The Plan denied your request. The Plan says the drugs that you received on the dates of 
service are considered self-administered. The Plan says self-administered drugs are covered under a Medicare 
Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part 
B. 
 
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 pay for the self-administered drugs 
provided from July 21, 2020, to July 22, 2020.  
 
Benefits for the self-administered drugs 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 a non-classified monitoring feature/device billed with CPT 
code A9279 for dates of service July 7 - August 7, 2020. 
 
You asked the Plan to pay for the non-classified monitoring feature/device. You say that the provider advised 
you that the Plan requires the modem for any CPAP delivered. You say that the Plan still denies paying 
anything towards the cost of this item. You say that you do not need the modem. The Plan denied your request. 
The Plan says the item in dispute is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that claims for A9279 are statutorily non-covered. Therefore, we 
decided that the Plan does not have to pay for a non-classified monitoring feature/device billed with CPT code 
A9279 for dates of service July 7 - August 7, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health aide services 
 
You asked the Plan to pre-approve home health aide services. You say that you need 4 additional home health 
aide services. The Plan denied your request. The Plan says the 4 additional home health aide services you are 
requesting are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide services. Our 
reviewer says that the service is not medically necessary and reasonable. Our physician reviewer found based 
on the medical records provided there is no documentation that the home health aide services are reasonable 
and necessary to the treatment of the patient's illness or injury by the skilled professional staff as the patient is 
no longer receiving skilled home health 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 home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the home health aide services
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical and occupational therapy. 
 
You asked the Plan to pre-approve physical and occupational therapy. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the service is not reasonable or necessary. 
 
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 physical and occupational therapy. Our 
reviewer says that the service is not medically necessary; there is no documentation that the specialized skill, 
knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to 
maintain the patient's current condition or to prevent or slow further deterioration. Our physician reviewer 
found that based on the medical records provided, there is no documentation that the requested therapy is 
generally accepted as specific and effective therapy for the patient's condition or that the unique skills of a 
professional therapist are required to safely and effectively provide treatment, that the services can be safely 
and effectively performed only by a therapist or under the supervision of a therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical and occupational therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve physical and occupational therapy.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for subsequent observation care provided on September 
6, 2020 and September 7, 2020. 
 
You asked the Plan to waive the copayment for subsequent observation care. You say that these were not 
different than the visit provided on September 8. You say that you shouldn't have to pay the copayments. The 
Plan denied your request. The Plan says that the copayments applied correctly. 
 
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. The Evidence of Coverage does not list the copayments for each service and the 
benefits insert was not submitted. This means that we cannot confirm if the copayments you are being asked to 
pay is correct or justified by the Plan contract. Therefore, we decided that the Plan has to waive the copayment 
for subsequent observation care provided on September 6, 2020 and September 7, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the chiropractic manipulative treatment 
(98941) provided from June 25, 2020, through July 14, 2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost sharing has been applied correctly to 
the services provided. 
 
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 after the yearly 
deductible of $500 is met, you must pay 50% for each Medicare-covered visit and non-Medicare covered 
routine visit for out of network chiropractic services.  
 
You have been asked to pay $120.54 ($40.18 x 3 visits) for the out of network Medicare-covered chiropractic 
services provided. This is the Plan allowed amount for these services, which has been applied to your yearly 
deductible. 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 copayment for the chiropractic manipulative treatment 
(98941) provided from June 25, 2020, through July 14, 2020.