Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that these services are medically necessary. The 
Plan denied your request. The Plan says there are in-network providers available. 
 
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 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be provided 
by a non-assigned dentist. 
 
You asked the Plan to pre-approve the comprehensive oral evaluation. You say that you have made every 
attempt to see a Plan approved dentist, but there are none in your area. The Plan denied your request. The Plan 
says unless your plan approves it, the Plan only covers services done by your assigned dentist. 
 
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, the requested items or services are not 
covered when they are received by anyone other than your assigned Plan dentist. Therefore, we decided that the 
Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be provided by a non-assigned 
dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that it is important for you to get the additional 
mileage approved to see the requested provider because they have developed a care plan that has improved you 
being able to do your daily functions. The Plan denied your request. The Plan says you are requesting an 
additional 109 miles for a total of 159 miles. Your benefit only allows 50 miles. The Plan also says that you 
have exceeded your benefit limit. 
 
  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage (A0170).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and the addition to lower extremity orthosis 
provided on September 10, 2020. 
 
You asked the Plan to pay for the knee orthosis and the addition to lower extremity orthosis. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the need for the 
items rendered is not supported by the documentation. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that there was no enrollee-provider relationship in the last 12 months 
prior to the date of service. In addition, the enrollee has not had any services related to a right or left knee 
condition in the prior 12 months. 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 knee orthosis 
and the addition to lower extremity orthosis provided on September 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic (CT) colonography screening 
(74263). 
 
You asked the Plan to pre-approve a CT colonography screening. The Plan denied your request. The Plan says 
this test is considered investigational. The Plan also says that the studies do not show that the enrollee will have 
a better outcome because of this test. 
 
The Plan must follow Medicare rules. Medicare rules say that all other indications for colorectal cancer 
screening not otherwise specified in the Act and regulations, or otherwise specified in the Medicare rules 
section remain nationally non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CT colonography screening have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomographic (CT) colonography screening (74263).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on January 30, 2022. 
 
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 70450 is a column II code to column I code 70496. 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 (70450) provided on January 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that you do not have documentation that it has been 18 months since 
your gastric surgery. 
 
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 requested services are not considered medically reasonable and necessary in this case. The record indicates 
that you have lost 100 pounds after bariatric surgery. The record provided does not document that you are 18 
months post bariatric surgery and that your weight has been stable for at least six months. Our physician 
reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a panniculectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory services provided on January 3, 
2022. 
 
You asked the Plan to waive the deductible for laboratory services. You say that you went to the provider for 
your annual wellness visit which should have zero cost. You also say that the Plan told you the reason for 
denial of payment is because of laboratory work that you did not request. The Plan denied your request. The 
Plan says the cost-share has been assessed correctly based on your contract with the Plan. You have been asked 
to pay $145.12 toward your deductible.  
 
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 $195 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies, such as laboratory services.  
 
The services you asked the Plan to waive the deductible for fall within the outpatient diagnostic tests and 
therapeutic services and supplies benefit category.  
 
 
 
 
 The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $195 deductible which 
applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual 
obligation that had not been met at the time the laboratory services were received on January 3, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on 
January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for remote diabetic monitoring provided on 
February 1, 2022. 
 
You asked the Plan to waive the coinsurance for the remote monitoring. You say that you were told there 
would be no charges due from you. The Plan denied your request. The Plan says the coinsurance was applied 
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 50% of 
the Medicare-allowed amount for Medicare-covered diabetic monitoring products/supplies.  
 
You have been asked to pay $100.14 for the remote monitoring. The remote monitoring falls within the 
Diabetes self-management training, diabetic 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 coinsurance for the remote diabetic monitoring provided on February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the epidural lysis of adhesions (62264) performed October 
18, 2021. 
 
You asked the Plan to pay for the procedure. You say that this procedure was medically necessary. The Plan 
denied your request. The Plan says the procedure is experimental and is non-covered. 
 
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 procedure. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the medical literature shows that current evidence on the safety and efficacy of endoscopic division of 
epidural adhesions does not appear adequate for this procedure to be used outside of research. More studies are 
needed to show safety and efficacy.  
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pay for the epidural lysis of adhesions (62264) performed October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for first-hour critical care (99291) provided on July 29, 2021. 
 
You asked the Plan to pay for first-hour critical care. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met 
because the available medical records do not support the service billed. 
 
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 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the available medical 
records do not indicate the span of time over which the services at issue were provided. The billed CPT code 
cannot be verified. Based on this information, we decided that Medicare rules for coverage of first-hour critical 
care have not been met. Therefore, we decided that the Plan does not have to pay for first-hour critical care 
(99291) provided on July 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no response, (A0998) 
provided on January 24, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that your brother called an ambulance for you. 
You say that by the time the ambulance arrived, the issue had resolved itself. You also say that you feel this 
should be covered under your plan. The Plan denied your request. The Plan says since there was no transport 
provided, there is no payable service. 
 
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 January 24, 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, no 
response, (A0998) provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of Plan's 
denial. The Plan denied your request. The Plan says the requested provider is not enrolled in Medicare, and per 
Medicare rules the Plan cannot authorize these services.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the case file indicates that the provider at issue is not enrolled in the Medicare program. Therefore, 
we decided that the Plan does not have to pre-approve acupuncture services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequence (NGS) testing panel provided 
on November 19, 2021. 
 
You asked the Plan to pay for the NGS testing panel. 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 a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
not covered. 
 
 
 
 
 We looked at the file and Medicare rules. Review of the file shows that the NGS testing provided included 
testing for the FANCC gene. This means the entire panel is not covered. Based on this information, we decided 
that Medicare rules for coverage of the NGS testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the next generation sequence (NGS) testing panel provided on November 19, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81445 billed for date of service July 26, 
2021. 
 
You asked the Plan to pay for procedure code 81445. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says payment for code 81445 is bundled into payment for code 
0018U. 
 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 81445 
is a column II code to column I code 0018U. 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 procedure code 81445 billed for date of service July 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 84166, 86335, and 86334 
provided on January 27, 2022 to January 30, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 codes 84166, 86335, and 86334 are not supported in the medical record. Specifically, this 
claim was billed with place of service 22 (outpatient hospital) however, the documentation supports that the 
enrollee was inpatient for these dates of service. This means this claim was billed with an incorrect place of 
service. Based on this information, we decided that Medicare rules for coverage of the laboratory services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 84166, 
86335, and 86334 provided on January 27, 2022 to January 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and treatment provided from April 1, 2021, 
through November 30, 2021. 
 
You asked the Plan to pay for the office visit and treatment. You say that you went to Missouri to help your 
daughter who had cancer and after she passed away you stayed there. You say you had contracted COVID-19 
and thought your health Plan coverage was good anywhere in the United States. The Plan denied your request. 
The Plan says you must receive care from a network provider in most cases. 
 
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 
services 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 an office visit and treatment provided from April 1, 2021, 
through November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the records provided support the need 
for the Intracept procedure. The Plan denied your request. The Plan says the requested procedure is unproven 
and not medically necessary due to insufficient evidence of efficacy. 
 
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 the Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has low back pain. Our physician reviewer found that the Intracept 
procedure is experimental. More research is 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure 
device (CPAP) and supplies for the enrollee. 
 
You asked the Plan to pre-approve continued CPAP and supplies use. You say that this is medically necessary. 
The Plan denied your request. The Plan says that the enrollee does not meet criteria for continued CPAP use. 
 The Plan must follow Medicare rules. Medicare rules say that you must use the PAP 4 hours per night on 70% 
of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. 
 
We looked at the file and Medicare rules. The compliance report included with the file indicates the enrollee 
did not adhere to therapy. Based on this information, we decided that Medicare rules for coverage of continued 
CPAP and supplies use have not been met. Therefore, we decided that the Plan does not have to pre-approve 
continued use of a continuous positive airway pressure device (CPAP) and supplies for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) and eye refraction (92015) provided 
on April 9, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam and refraction. You say that this service was for an annual eye 
exam. You also say that you are allowed 1 routine eye exam per year with a $0 copay and do not understand 
why this claim was denied. The Plan denied your request. The Plan says you were seen for an eye exam and 
refraction from an OON provider. The Plan also says that these services are not covered if rendered OON. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the exam and refraction are received by an in-network provider. 
 
We looked at the file and the Plan's rules. The record shows that these services were rendered by an OON 
provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam and 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam 
(92014) and eye refraction (92015) provided on April 9, 2022 by an out-of-network (OON) provider.