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

 
We decided that the Plan does not have to pay for the Tempus xT testing (81455) provided on August 5, 2022. 
 
You asked the Plan to pay for the Tempus xT testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this is not a covered test. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xT testing is not FDA approved. 
Based on this information, we decided that Medicare rules for coverage of the Tempus xT testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the Tempus xT testing (81455) provided on 
August 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
magnetic resonance imaging (MRI) to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for radiological services billed with code 73502-26-RT provided on 
October 13, 2022. 
 
You asked the Plan to pay for radiology services provided. You say that  The Plan denied your request. The 
Plan says that the diagnosis is inconsistent with the procedure. 
 
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. We find that the specific denial rationale offered by the Plan is not supported. 
The enrollee does have artificial hips so the diagnosis of secondary code Z96.643, described as presence of 
artificial hip joint, bilateral is appropriate even though only one side was imaged. As such, we find that the 
denial of payment on this basis is not substantiated. 
 
Therefore, we decided that the Plan has to pay for radiological services billed with code 73502-26-RT provided 
on October 13, 2022.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
November 10, 2022, to November 11, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for emergency room services. This item/service 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 emergency room services 
provided on November 10, 2022, to November 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on October 20, 2022. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 75716-59 is a column II code to column I code 37221; however, 
75716-59 was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for radiology services provided. Our reviewer says that 
documentation does not support the billed code Our reviewer found that the enrollee underwent bilateral lower 
extremity angiography with radiological interpretation on October 20, 2022. This procedure is considered 
inclusive to code 37221-50. The review indicates that requested service was not substantiated in the operative 
report. The review has determined that the documentation did not support that code 75716 was distinct from 
code 37221. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiology services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for radiological services provided on October 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on October 8, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that medical 
attention was critical due to your low blood sugar for your diabetes. You also say that after the paramedics 
treated you, you felt much better and declined the transport. 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 October 8, 2022. 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 response and treatment with no 
transport provided on October 8, 2022.
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. 
 
You asked the Plan to pre-approve IRF care. You say that you need more aggressive rehabilitation to resume 
your quality of life. The Plan denied your request. The Plan says the denial of IRF care is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you have progressed very well in a skilled nursing facility (SNF) and are ambulating 
at a community level. You do not require intensive rehabilitation to continue progress or maintain your current functional level. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 06, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on December 06, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lens prosthesis adjustment provided on 
January 31, 2022. 
 
You asked the Plan to waive the copayment for the lens prosthesis adjustment. You say that this procedure was 
needed due to a providers mistake. The Plan denied your request. The Plan says this cost sharing was charged 
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 $150 
copayment for outpatient sugery at an ambulatory surgical center. 
 
You have been asked to pay a $150 copayment for the lens prosthesis adjustment. This item/service falls within 
the outpatient sugery at an ambulatory surgical center 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 the lens prosthesis adjustment provided on January 31, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on October 24, 2022. 
 
You asked the Plan to pay for the billed services. You say that precertification for this service is not needed. 
The Plan denied your request. The Plan says there was no documented contact with the attending physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. The record does not include documentation of a consultation or an 
attempt to consult the enrollee's primary/attending physician as required. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for the psychotherapy services provided on October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on November 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 15, 2022 and July 
19, 2022. Therefore, we decided that the Plan does not have to pay for a cleaning (D1110) provided on 
November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standby service, requiring prolonged attendance, each 30 
minutes (99360) provided on September 13, 2022. 
 
You asked the Plan to pay for the standby service. You say that the surgeon believed the service was needed at 
the time of the surgery. The Plan denied your request. The Plan says standby services are not payable to 
physicians. 
 
The Plan must follow Medicare rules. Medicare rules say that physicians may not bill Medicare or beneficiaries 
for standby services.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the standby service have not been met. Therefore, we decided that the Plan does not have to pay 
for the standby service, requiring prolonged attendance, each 30 minutes (99360) provided on September 13, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a magnetic resonance imaging (MRI) 
provided on December 12, 2022. 
 
You asked the Plan to reduce the copayment for an MRI. You say that you say that you were charged more 
than you intended to be billed. The Plan denied your request. The Plan says this cost sharing was charged 
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 $275 
copayment per day, per provider, for Medicare covered diagnostic radiology services.  
 
You have been asked to pay a $203.95 copayment for an MRI because the allowed amount for this service is 
less than the $275 copayment. This item/service falls within the in-network outpatient diagnostic tests and 
therapeutic services and supplies 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 reduce the copayment for a 
magnetic resonance imaging (MRI) provided on December 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve a group 2 power wheelchair with multiple power options. You say that the 
enrollee's health has declined and requires the items to safely complete in-home activities of daily living. The 
Plan denied your request. The Plan says the enrollee does not need a Group 2 power wheelchair with the 
requested power options. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 group 2 power wheelchair with 
multiple power options. Our reviewer says that the requested items are not medically necessary. Our physician 
reviewer found the documentation does not consistently support that this enrollee requires the requested power 
wheelchair and accessories and that it will significantly improve mobility-related activities of daily living 
function in the home. Furthermore, the documentation does not reveal that the enrollee is at high risk for 
development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power 
seating system to manage increased tone or spasticity. Therefore, the request for power wheelchair and power 
and tilt exceeds the enrollee's medical needs. 
 
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 group 2 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair with multiple 
power options.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (83521) provided on April 7, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you expected these services to be paid because 
they had been covered for all of 2021. You say there may be a coding issue, but these are the same services you 
had been receiving previously. The Plan denied your request. The Plan says that these services are considered 
experimental/investigational and are considered not medically necessary. 
 
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 laboratory services by a contract provider. The file does not show that the Plan provided 
notice that laboratory services would not be covered. Under Medicare rules, this means laboratory services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for laboratory services (83521) 
provided on April 7, 2022.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service April 14, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says manifestation 
codes are not used as principal diagnosis codes. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99285 was billed with principal diagnosis code F02.81, dementia in other diseases 
classified elsewhere with behavioral disturbance. In diseases classified elsewhere codes are never permitted 
to be used as first listed or principal diagnosis codes. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99285 billed for date of service April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chronic care management visit provided on September 21, 
2022. 
 
You asked the Plan to pay for a chronic care management visit. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a chronic care 
management visit provided on September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit provided on June 28, 2022. 
 
You asked the Plan to waive the deductible for the office visit. You say that you thought this would be the fully 
covered annual wellness visit. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 an $800 deductible which applies to doctor and other health care 
provider services.  
 
The records show that an annual wellness visit was provided on December 29, 2021. The item or service you 
asked the Plan to waive the deductible for falls within the doctor and other health care provider services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is an $800 
deductible which applies to doctor and other health care provider services. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on June 28, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible for the office visit provided on June 28, 2022.
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. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of IRF care is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have complex or intensive rehabilitation needs. The enrollee's 
needs can be reasonable managed at an outpatient level and do not represent barriers to continued outpatient rehabilitation. 
 
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.