Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
the denial. The Plan denied your request. The Plan says based on Medicare guidelines, the long-term acute care 
hospital services you are requesting do not meet the requirements for approval. 
 
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 has a history of depression, hypertension, and schizophrenia who 
presented with fecal impaction and urinary retention. The enrollee was taken to the operation room and had a 
catheter placement. The enrollee also had a small bowel obstruction ileus and had a nasogastric tube (NG) 
placed for decompression. Currently the enrollee is maintained on total parenteral nutrition and NG tube as the 
abdomen is still distended. The enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
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 the LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 25, 2022 billed with 
codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81335, 81355, 
81407. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing was not billed using the appropriate coding. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.   
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 25, 2022 billed with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81238, 81291, 
81306, 81335, 81355, 81407.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on July 17, 2020. 
 
You asked the Plan to pay for the medical services. You say that insurance information given to you was 
incorrect.  You said that you filed this claim as soon as you received correct insurance information. The Plan 
denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services was not filed until March 21, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for medical services provided on July 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power standing system (E2301) and a chest support 
and hardware (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you are quadriplegic and the power 
standing feature is the only way you are able to exercise and to keep strength in your legs. It is important for 
you to stand and not sit all of the time, due to your skin on your bottom breaking down. The Plan denied your 
request. The Plan says the requested power standing system and the chest belt associated with the power 
standing system cannot be approved as it does not serve a medical purpose and is statutorily non-covered. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power standing system (E2301) and a chest support and 
hardware (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the patient does not go there to your laboratory, 
so he/she is not using out-of-network benefits as the participating provider sends you the specimens to process. 
The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan 
also says that these services were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan 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 laboratory services provided on May 18, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Continuous positive airway pressure (CPAP) machine 
provided on March 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for CPAP machine. You say that you were told your insurance would pay 80% of 
the cost. You say that you didn't find out until later the provider was out-of-network. The Plan denied your 
request. The Plan says the service can be provided by an in-network provider. 
 
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 Continuous positive airway pressure (CPAP) 
machine provided on March 11, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve grocery benefits. 
 
You asked the Plan to pre-approve grocery benefits. You say that your primary has been your doctor for over 
seven years. The Plan denied your request. The Plan says you do not meet the criteria for this benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of grocery benefits have not been met. Specifically, we have confirmed that you do not meet all the 
criteria listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve 
grocery benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intermittent urinary catheter (A4351), lubricant (A4332) 
and a bedside drainage bag (A4357) provided on February 16, 2021. 
 
You asked the Plan to pay for a urinary catheter, lubricant and a bedside drainage bag. You say that you are 
requesting reconsideration because you originally submitted this claim to another payer. You also say you have 
attached proof that the claim was submitted timely. The Plan denied your request. The Plan says the claim was 
submitted untimely, and the submission did not meet the exception criteria guidelines. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for a urinary catheter, lubricant and a bedside drainage bag was not filed until 
March 1, 2022. This means that more than one calendar year from the date of service had passed before a claim 
was filed. Therefore, we decided that the Plan does not have to pay for an intermittent urinary catheter 
(A4351), lubricant (A4332) and a bedside drainage bag (A4357) provided on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on February 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on February 22, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan of the lower extremity. 
 
You asked the Plan to pre-approve an MRI scan. You say that an MRI scan is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that there was no provided results of an x-ray taken after 
the enrollee's symptoms started or changed that show a need for further imaging; therefore, an MRI scan is not 
medically necessary. 
 
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 an MRI scan. Our reviewer says that 
the MRI of the lower extremity is medically needed at this time. Our physician reviewer found that the enrollee 
has osteopenia. Plain x-rays were done in April revealing moderate degenerative joint disease. Based upon the 
clinical symptoms and the x-ray findings the MRI of the right hip should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI scan have been met. Therefore, we decided that the Plan has to pre-
approve a magnetic resonance imaging (MRI) scan of the lower extremity.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the leg 
joint without contrast. 
 
You asked the Plan to pre-approve an MRI scan. You say that it is medically necessary for the enrollee to get 
an MRI scan done. The Plan denied your request. The Plan says the records did not show what type of hip 
problem the enrollee is suspected of having; therefore, an MRI scan is not medically necessary at this time. 
 
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 an MRI scan. Our reviewer says that 
the MRI of the leg joint without contrast is not medically needed at this time. Our physician reviewer found 
that the enrollee has a medical history of right hip pain. A clinical progress noted dated May 19, 2022, 
indicated that the enrollee was being evaluated for lumbosacral spondylosis. The enrollee has a history of 
lumbar spine fusion at L4-5 in April of 2021. The enrollee was referred for potential spinal cord stimulator 
placement and medial branch blocks. A clinical progress notes dated February 18, 2022, indicated that the 
enrollee was evaluated for right shoulder pain and neck pain. The enrollee has had cervical spine facet joint 
injections as well as a right shoulder intra-articular joint injection. The enrollee was noted to have near 
resolution of right hip pain following an intra-articular injection on August 24, 2020. Radiographs of the right 
hip were noted to be unremarkable. 
 
  The enrollee has been receiving multiple injections for control of his hip, neck, and low back pain. This 
includes an intra-articular injection of their right hip which was noted to significantly reduce his pain. The 
enrollee has failed to respond to physical therapy, but this regarding their lower back pain. There is insufficient 
information, including clinical history and physical examination findings, regarding the potential etiology of 
the enrollee's right sided hip pain and why an MRI is required. Radiographs of the right hip were noted to be 
normal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a magnetic resonance imaging (MRI) scan of the leg joint without contrast.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit provided on March 
17, 2022, by an OON provider. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that our physician treated the 
enrollee at the facility and they do not have an authorization for them. We depend on the hospital staff to verify 
eligibility and to obtain the proper authorization from the enrollee's Plan. The Plan denied your request. The 
Plan says the out-of-network services were not authorized. 
 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 subsequent nursing facility care visit provided 
on March 17, 2022, by OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an at home COVID test purchased on April 11, 2022. 
 
You asked the Plan to pay for COVID test. You say that this test is required for you to return to the United 
States. The Plan denied your request. The Plan says the Plan is not responsible for coverage of this test. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers up to 8 over-the-counter (OTC) 
COVID-19 tests each month; however, Medicare Advantage plans are not responsible for payment of these 
tests.  
 
We looked at the file and Medicare rules. The Plan is not responsible for payment of this test. Based on this 
information, we decided that Medicare rules for coverage of COVID test have not been met. Therefore, we 
decided that the Plan does not have to pay for an at home COVID test purchased on April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 laboratory services provided on April 28, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services provided on March 31, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical pathology services. You say that the doctor's office failed to send the 
preauthorization form for approval. The Plan denied your request. The Plan says no prior authorization was 
obtained. 
 
 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 
surgical pathology services. We found no exception that would require the Plan to pay for the surgical 
pathology services. The records provided for review do not show that the services at issue were urgent or 
emergent. Therefore, we decided that the Plan does not have to pay for the surgical pathology services provided 
on March 31, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on March 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on March 15, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on January 18, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92004) provided on May 19, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that your policy clearly states that eye exams are covered. 
The Plan denied your request. The Plan says the treating provider is not part of the Plan's Vision network. The 
Plan also says that OON providers are not covered under your plan.  
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 you use a provider in the Plan's specialty medical network. 
 
We looked at the file and the Plan's rules. The record shows that you received this eye exam from an OON 
provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not 
been met. Therefore, we decided that the Plan does not have to pay for the eye exam (92004) provided on May 
19, 2022, by an out-of-network (OON) provider.