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

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from inpatient rehabilitation 
services due to your medical complexity. The Plan denied your request. The Plan says your needs can be met at 
a lower level of care such as skilled nursing facility (SNF), home health or outpatient therapy. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  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 acupuncture services (97810, 97811) provided on November 
8, 2021. 
 
You asked the Plan to pay for acupuncture services. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not provided by a qualified provider. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments provided by a physician in accordance with state requirements, or by physician assistants, nurse 
practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, 
physician assistant, or nurse practitioner/clinical nurse specialist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the record does not show that these services were 
provided by or under the supervision of a physician, physician assistant, or nurse practitioner/clinical nurse 
specialist. Therefore, we decided that the Plan does not have to pay for acupuncture services (97810, 97811) 
provided on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from September 7, 2021, to 
September 14, 2021. 
 
You asked the Plan to pay for chiropractic services. The Plan denied your request. The Plan says you have 
exhausted your 30 visits. 
 
The Plan contract covers chiropractic services. The Plan benefit covers up to 30 visits per year. 
 
We looked at the file and the Plans rules. The file shows that you have exhausted the chiropractic services 
benefit. Therefore, we decided that the Plan does not have to pay for chiropractic services provided from 
September 7, 2021, to September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 19, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are aware that the provider is not contracted and 
were advised when joining the Plan you could continue to see your previous physicians. 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 an office visit provided on May 19, 2022, by OON 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for upper gastrointestinal endoscopic procedures, 
endoscope introduced proximal to duodenum; not otherwise specified provided to the enrollee on April 15, 
2022. 
 
You asked the Plan to pay for the serivces. You say that this should be paid for. The Plan denied your request. 
The Plan says there is a missing or invalid diagnosis. 
 
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 00731 is "Anesthesia for upper gastrointestinal 
endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified." 
 
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 the serivces. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the anesthesia billing code CPT 
00731 has not met the associated diagnosis code relationship criteria due to a missing or invalid diagnosis/ICD-
10 code. The criteria for coverage for CPT 00731, billed with diagnosis code Z21.9, have not been met.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the serivces have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to 
duodenum; not otherwise specified provided to the enrollee on April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this provider regularly complies with all 
administrative requirements for payments. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan and the services were not referred by a network provider. 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 an office visit provided on June 29, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for a Tempus Liquid Biopsy panel (81455) provided on May 19, 2022. 
 
You asked the Plan to pay for a Tempus Liquid Biopsy panel. You say that this was medically necessary. The 
Plan denied your request. The Plan says that this must be billed with the collection date as the date of service. 
 
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 rules also state that the date of service (DOS) for laboratory tests generally must be the date the 
specimen was collected; however, there are exceptions for molecular pathology tests performed by a laboratory 
other than a blood bank. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided information to support that the testing at issue does 
not meet the exceptions that allow the date of service to be the date the testing was performed. Therefore, we 
decided that the Plan has to pay for a Tempus Liquid Biopsy panel (81455) provided on May 19, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) scan provided on March 04, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for CT scan. You say that you are working on becoming in-network with the Plan 
and the member originally presented a Medicare card. The Plan denied your request. The Plan says The 
enrollee must use network providers. If the enrollee receives unauthorized care from an out-of-network 
provider, we may deny coverage and the enrollee will be responsible for the entire cost. 
 
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 computed tomography (CT) scan provided on 
March 04, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee had hip surgery after their surgery they 
had significant changes with hip fracture and needs therapy. The Plan denied your request. The Plan says the 
criteria for admission to the Acute Inpatient Rehabilitation setting have not been met. The enrollee's ongoing 
skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 16, 2022, billed with 
codes 0031U, 0032U, 81225, 81227, 81230, 81231, 81291, 81328, 81355 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare billing regulations. 
 
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 16, 2022, billed with codes 0031U, 0032U, 81225, 81227, 81230, 81231, 81291, 81328, 81355 and 
81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assessment of and care planning services provided on 
April 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the assessment of and care planning services. You say that the service was 
rendered to the enrollee out of medical necessity, and you would like the claim paid. The Plan denied your 
request. The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 assessment of and care planning services 
provided on April 20, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse payment for the catheters provided from November 21, 
2021, to March 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to reimburse payment for the catheters. You say that you would like the Plan to reimburse 
you for the paid services. The Plan denied your request. The Plan says the rendering provider the enrollee used 
is an OON provider and there are in-network providers available that provide the same service as the OON 
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 reimburse payment 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 reimburse payment for these 
items/services. Therefore, we decided that the Plan does not have to reimburse payment for the catheters 
provided from November 21, 2021, to 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 the office visit (99214), thoracic spine x-ray (72070), and 
lumbosacral spine x-ray (72100) provided on April 14, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were rendered to the enrollee in 
good faith. The Plan denied your request. The Plan says payment cannot be made for services performed by a 
provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visit (99214), thoracic spine x-ray (72070), and lumbosacral spine x-ray (72100) provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided by an out-of-network 
provider on May 17, 2022. 
 
You asked the Plan to pay for the hearing aids (V5261). You say that you were under the impression that the 
doctor was in-network and that you would receive the $1,000 credit per ear. The Plan denied your request. The 
Plan says the provider was out-of-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when ordered through in-network providers.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids (V5261) have not been met. Specifically, the provider was out-of-network. 
Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) provided by an out-of-
network provider on May 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says according to the available records, you do not meet all the required Medicare criteria for 
admission to an IRF. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute 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 May 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like a retroactive prior authorization 
request for the service. The Plan denied your request. The Plan says prior authorization was not 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 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 an office visit provided on May 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital service provided on 
May 5, 2022. 
 
You asked the Plan to waive the copayment for surgical service. You say that you assumed that the Plan denied 
the room charge because it was a cosmetic treatment. 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 $300 
copayment for outpatient hospital surgery service.  
 
You have been asked to pay $144, which is less than the $300 copayment for surgical service. This 
item/service falls within the outpatient hospital surgery service 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 outpatient hospital service provided on May 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80053, 36415, 85025) provided on April 
18, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the services denied correctly as they 
were non-emergent and prior authorization was not 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 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 (80053, 36415, 85025) 
provided on April 18, 2022 by an out-of-network (OON) provider.