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

 
We decided that the Plan does not have to pay for Home Visit services provided on August 16, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Home Visit services. You say that the member presented the incorrect insurance 
card at the time of service and the office was unable to obtain authorization. The Plan denied your request. The 
Plan says the provider is out-of-network and authorization is required prior to an out-of-network visit. 
 
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 had network providers 
available who could have provided 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 Home Visit services provided on August 16, 2021 
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 services (99233) provided on October 21, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
service. 
 The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one 
previously processed and paid by the Plan. Duplicate claims are not payable. 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 the services (99233) provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on January 18, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you have seen this provider before, and 
you received a referral from your primary care provider. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral on file for the rendering provider prior to the 
date of service. 
 
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 had network providers 
available who could have provided 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 a specialist office visit provided on January 18, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have chronic low back pain and 
had right SI joint RFA that provided 100 percent pain relief for eight months. The requested RFA of the SI 
joint is considered experimental/investigational in nature due to its wide variation of effectiveness. The services 
are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met.  
  
Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the 
sacroiliac (SI) joint.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (75743) provided on October 23, 2021. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 75743 
is a column II code to column I code 37184. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 services (75743) provided on October 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and improving and should only require short-
term acute care hospital services that can be safely completed at the current facility until more appropriate for a 
lower level of care. There are no services at the LTACH that the enrollee requires that are not already available 
and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically 
advantageous at this time. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer bench, heavy duty, for tub or toilet with or 
without commode opening (E0248). 
 
You asked the Plan to pre-approve a transfer bench. You say that the item is necessary. The Plan denied your 
request. The Plan says the specific item requested above is excluded in your designated DME term of coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that the transfer bench is not covered because it is not 
primarily medical in nature.  
 
While a transfer bench may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a transfer bench, heavy duty, for tub or 
toilet with or without commode opening (E0248).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for CPAP) machine and supplies on January 
26, 2022. 
 
You asked the Plan to waive the coinsurance for CPAP machine and supplies. You say that you were unable to 
use the machine until February 18, 2022, so you don't feel like you should have to pay for something that didn't 
work. The Plan denied your request. The Plan says the coinsurance applied is correct. 
 
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 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
 You have been asked to pay $59.29 which is the 20% coinsurance for CPAP machine and supplies. The 
allowed amount is $296.45 (20% x $296.45 = $59.29). The CPAP machine and supplies fall within the durable 
medical equipment (DME) and related 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 waive the 
coinsurance for CPAP) machine and supplies on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99205) provided on August 18, 2021. 
 
You asked the Plan to pay for the physician service. You say that the services you are requesting 
reimbursement for are services that are included in the service that you paid $750 for. You also say that you 
were expecting $400 in reimbursement. The Plan denied your request. The Plan says the office visit is not 
covered under the Wellness Wallet benefit. 
 
Medicare generally does not cover supplemental services. However, the Plan offers a supplemental benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a supplemental benefit in excess of Medicare coverage, the physician service you 
received is not among those covered under this benefit. Specifically, the office visits, labs, vitamins and 
hormones that you received are not part of the Wellness Wallet benefit. Therefore, we decided that the Plan 
does not have to pay for the office visit (99205) provided on August 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the pelvis and 
lower extremity. 
 
You asked the Plan to pre-approve the requested imaging. The Plan denied your request. The Plan says the 
enrollee has not had six weeks of conservative treatments. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 requested imaging. Our physician 
reviewer found that the enrollee has generalized osteoarthritis with reported right low back pain and right hip 
pain without reported injury. She denied numbness or tingling. She reported having seen another provider for 
and had imaging which was negative. Decreased range of motion and tenderness was noted at the lower back, 
however, no provocative testing or hip or leg exam findings were noted. The provided documentation did not 
clearly describe the enrollee having tried and failed conservative treatments for at least 4-6 weeks to support 
advanced imaging at this time. Nor was there abnormal first-line imaging reports that required follow-up 
testing with an MRI. Also, there were no red flag diagnosis noted from physical exam or history to justify 
bypassing the above steps. The enrollee was referred to physical therapy, but not yet initiated. Therefore, the 
MRI pelvis and lower extremity will be considered not medically necessary or reasonable at this time. 
 
 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 requested imaging have not been met. Therefore, we decided that the Plan 
does not have to pre-approve magnetic resonance imaging (MRI) of the pelvis and lower extremity.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on December 2, 2021. 
 
You asked the Plan to waive the copayment for ultrasound. You say that every time you go the doctor you must 
pay. You say that you pay for insurance therefore this should be covered. The Plan denied your request. The 
Plan says coinsurance is correct. 
 
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 $100 per 
day for a Medicare-covered ultrasound.  
 
  You have been asked to pay $100 for the ultrasound. The ultrasound falls within the 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 waive the copayment 
for ultrasound provided on December 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee's needs are being met in the current acute 
setting and the LTACH would offer no additional services to the enrollee. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 0037U) provided on 
December 8, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says they cannot determine how the member came to the servicing provider or whether 
the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services (CPT code 0037U) provided on December 8, 2021. have been met. There are no clinical records from the treating 
physician who ordered the testing to verify the services were necessary. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (CPT code 0037U) provided on December 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing evaluations provided on October 2, 2021, 
and October 26, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the skilled nursing evaluations. You say that there was no adequate time to 
obtain authorization for service and would like the claim reprocessed for payment because it was medically 
necessary to treat the enrollee. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no approved 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 had network providers 
available who could have provided 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 skilled nursing evaluations provided on 
October 2, 2021, and October 26, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus Gene Panel testing provided on September 1, 2021. 
 
You asked the Plan to pay for the Tempus Gene Panel testing. You say that the claim should be paid. The Plan 
denied your request. The Plan says the services are not covered as billed. 
 
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 pay for the Tempus Gene Panel testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation submitted was reviewed and does not meet criteria. The 
documentation does not include enough documentation to support the level of service provided. As the only 
documentation submitted was diagnosis code, with no additional supporting documentation.  Medicare's 
coverage for genetic testing is limited, and documentation does not support level of service provided. 
 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 Tempus Gene Panel testing have not been met. Therefore, we decided that 
the Plan does not have to pay for Tempus Gene Panel testing provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on July 8, 
2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that the attached records 
substantiate the medical necessity and payment should be issued for the services provided. The Plan denied 
your request. The Plan says procedure code 01992 has been overturned and procedure code 99100 remains 
denied as bundled services are not eligible for separate reimbursement.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingrix vaccine (90750) and immunization 
administration (90471) provided January 18, 2022. 
 
You asked the Plan to pay for the Shingrix vaccine. You say that you received a bill from your provider for a 
shingles vaccine for $475.00. You should not have to pay for it and your doctor should have known it was not 
covered in the office. The Plan denied your request. The Plan says the Shingrix vaccine is covered as a Tier 3 
medication under your Part D benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingrix 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Shingrix 
vaccine. Therefore, we decided that the Plan does not have to pay for the Shingrix vaccine (90750) and 
immunization administration (90471) provided January 18, 2022.  
 
Benefits for the Shingrix vaccine 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 pre-approve a walker to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve a walker. You say that you would like to appeal the denial of the claim. 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 
a walker to be provided by an out-of-network (OON) provider.