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

We decided that the Plan has to pay for the physician services provided from June 29, 2021, to August 24, 
2021.

You asked the Plan to pay for the services provided. You say that the provider has been treating you for the 
past two years. The Plan denied your request. The Plan says that the services were billed without a CPT or 
revenue code.

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.

We looked at the file and the rules. The file shows that you received opiate treatment visits on June 29, 2021, 
July 27, 2021, and August 24, 2021. The Plan has not shown there are available contract providers for the 
services at issue. The case file does not show that the Plan has made sufficient efforts to ensure continuity of 
care. You do not have control over coding issues for the services you receive. There is no indication that the 
Plan has provided sufficient guidance in the processing of the services provided. Furthermore, the Plan has not 
provided Medicare rules or regulations to support their decision. The Plan has not made reasonable and diligent 
efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we 
decided that the Plan has to pay for the physician services provided from June 29, 2021, to August 24, 2021.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a
participating provider on March 1, 2021, to March 31, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that you did not move to a private
room. You say that the Plan should pay for this. The Plan denied your request. The Plan says the correct
copayments have been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35
copayment for outpatient rehabilitation services/in-network.
You have been asked to pay a $35 copayment per session for physical therapy. You have been asked to pay a
total of $805 ($35 x 23 sessions = $805). Physical therapy falls within the outpatient rehabilitation services/in-
network 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 physical therapy provided
by a participating provider on March 1, 2021, to March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services (97810, 97811) provided on March
25, 2021.
You asked the Plan to pay for the acupuncture services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says the services were rendered by a provider
type that is not covered per the Plan's contract with the enrollee.
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 for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case. The Plan specifies that acupuncture services must be provided by a legally
qualified physician practicing within the scope of their license.
We looked at the file and Medicare rules. In this case, the acupuncture services were rendered by a licensed
acupuncturist and not a physician as required by the Plan's contract. Based on this information, we decided that
the rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does
not have to pay for the acupuncture services (97810, 97811) provided on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on September 15, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a domiciliary or rest home visit. You say that authorization was not obtained prior to seeing this patient since it is the nursing facility's responsibility to get authorizations for their patients. You also say that it was medically necessary for the patient to receive the treatment by this provider. 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 urgent or emergent, nor were they 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 a domiciliary or rest home visit (99336) provided on September 15, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx-SCC testing provided on September 7, 2021.

You asked the Plan to pay for the DecisionDx-SCC testing. You say that the DecisionDx-SCC testing provided
on September 7, 2021, was medically necessary. The Plan denied your request. The Plan says the DecisionDx-
SCC testing provided on September 7, 2021, was 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 pay for the DecisionDx-SCC testing. Our reviewer
says that the DecisionDx-SCC testing provided on September 7, 2021, was not medically necessary.

Our physician reviewer found the DecisionDx-UM test is intended for determination of metastatic risk, and to
guide surveillance and referral to medical oncology in patients who have a confirmed diagnosis of uveal
melanoma (UM) and no evidence of metastatic disease. The test discriminates patients with high risk (class 2)
for early distal recurrent disease from those with minimal risk of distal metastasis (class 1A). Identification of
high-risk patients allows early referral to a medical oncologist with expertise in the management of uveal
melanomas, which includes intensified metastatic surveillance and/or metastasis intervention, and stratification
for entry into clinical trials with adjuvant therapy. National Comprehensive Cancer Network (NCCN)
Guidelines for SCC doesn't indicate DecisionDx-SCC for treatment guidance. The review has determined that
the DecisionDx-SCC testing provided on September 7, 2021, was not medically reasonable and necessary for
the enrollee.

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 DecisionDx-SCC testing have not been met. Therefore, we decided that the
Plan does not have to pay for the DecisionDx-SCC testing provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and related services provided on June 22, 
2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the medical services. You say that the documentation supports the medical 
necessity of the services rendered. The Plan denied your request. The Plan says prior authorization was not 
obtained for these services rendered by an 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 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. There is no evidence that the services were rendered after a referral from the enrollee's 
primary care physician. 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 office visit and related services provided on 
June 22, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 14, 
2021, to January 18, 2021.

You asked the Plan to pay for the inpatient care provided from January 14, 2021, to January 18, 2021. You say 
that the services were medically necessary. The Plan denied your request. The Plan says the services rendered 
on the dates of service in question were 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 pay for the inpatient care provided from January 14, 
2021, to January 18, 2021. Our reviewer says that the inpatient care provided from January 14, 2021, to 
January 18, 2021 was not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided documentation indicates that ass of January 14, 2021 the enrollee was medically stable and 
awaiting transfer to a rehabilitation facility. The reviewer found that for the period January 14, 2021, to 18, 
2021 the enrollee did not require or receive any inpatient level of care services. Therefore, the reviewer found 
that the inpatient care provided from January 14, 2021, to January 18, 2021 was not medically reasonable and 
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 the inpatient care provided from January 14, 2021, to January 18, 2021 have not 
been met. Specifically, the file indicates that the enrollee was waiting for transport to a rehabilitation facility 
and did not receive any inpatient level of care services. Therefore, we decided that the Plan does not have to 
pay for the acute inpatient hospital care provided from January 14, 2021, to January 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3216, L3020).
You asked the Plan to pre-approve foot orthotics. You say that the orthotics are medically necessary. The Plan
denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3216, L3020).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mouth guard (E1399).
You asked the Plan to pre-approve the mouth guard. You say that the oral appliance is medically necessary.
The Plan denied your request. The Plan says the requested appliance is not for the treatment of sleep apnea and
is considered a dental item. This item is non-covered.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a mouth guard
(E1399).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the body fracture augmentation provided
on September 14, 2021.
You asked the Plan to waive the copayment for the body fracture augmentation. You say that you are new to
this plan and did not know you could no longer go where you always went. The Plan denied your request. The
Plan says the denied claim for services rendered on this date will be sent to be reprocessed according to your
benefits. The Plan also says the $325 copayment 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 a $325
copayment for outpatient surgery.
You have been asked to pay a $325 copayment for the body fracture augmentation. The body fracture
augmentation falls within the "Outpatient surgery, including services provided at hospital outpatient facilities
and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
the body fracture augmentation provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical eye exam and refraction services (92014, 92015) provided on August 31, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the ophthalmology services. You say that these services were medically necessary based on the enrollee's condition. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an 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 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 medical eye exam and refraction services (92014, 92015) provided on August 31, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the gait training therapy (97116), therapeutic activities
(97530), and therapeutic exercises (97110) provided on July 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the gait training therapy, therapeutic activities, and therapeutic exercises. You
say that the services rendered were medically necessary, and you believe this claim should be reprocessed for
payment. The Plan denied your request. The Plan says these services were rendered by a non-participating
provider. The Plan also says that 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 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 gait training therapy (97116), therapeutic
activities (97530), and therapeutic exercises (97110) provided on July 9, 2021 by an out-of-network (OON)
provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography angiography (CTA) of the head 
rendered on September 11, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 70544 (CTA head) and 70551 (magnetic resonance 
imaging of the brain stem). Code 70544 is a column II code with a modifier indicator of 1 when billed with 
column I code 70551. Code 70544 was not billed with an appropriate modifier to allow for separate payment.

Therefore, we decided that the Plan does not have to pay for the computed tomography angiography (CTA) of 
the head rendered on September 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for routine electrocardiogram (ECG) with at 
least 12 leads, including the tracing, interpretation, and report (93000) provided July 8, 2021.

You asked the Plan to waive the copayment for the diagnostic service. You say that you cannot make sense of 
the $14.05 charge. The amount allowed should cover the total, but the Plan paid $14.05 short the amount 
allowed. The Plan denied your request. The Plan says the claim was processed with the correct copayment 
applied per the Evidence of Coverage

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 
copayment for Medicare covered non-radiological diagnostic services. 

You have been asked to pay $14.05 for the diagnostic service. Since the Allowed amount was less than the 
copayment amount, you are responsible for the lesser amount. the diagnostic service 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 routine electrocardiogram (ECG) with at least 12 leads, including the tracing, interpretation, and 
report (93000) provided July 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from May 4, 2020, 
through May 5, 2020, as billed.

You asked the Plan to pay for the inpatient hospital as billed. You say that the documentation supports the 
inpatient care as it was originally billed. The Plan denied your request. The Plan says there is no support in the 
medical records submitted for the billed principal and secondary diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
In this case, you billed the inpatient services provided with principal diagnosis code, I12.9, defined as 
unspecified kidney disease and secondary diagnosis code, N17.9, defined as kidney failure. 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 inpatient hospital as billed. Our reviewer says that the 
documentation does not support the billed principal and secondary diagnosis. Our physician reviewer found 
that the documentation indicates that the enrollee was a then 79-year-old female, with a history of coronary 
artery disease, hypertension, stage IV chronic kidney disease, pulmonary embolism, gastroesophageal reflux 
disease and hyperlipidemia, who presented for evaluation on May 2, 2020, reporting left-sided chest pain. 
Presenting vital signs included a temperature of 98.4F with a pulse of 81/minute, blood pressure of 146/56 and 
respirations of 18/minute with a room airpulse oximetry reading of 99%. The white blood cell count was 
7.1K/uL with a hemoglobin of 11.0g/dL, a hematocrit of 35.1% and platelet count of 189K/uL. The serum pro-
BNP level was 296pg/mL. The serum troponin T level was less than 0.01ng/mL. The serum creatinine level 
was 3.2mg/dL with a BUN of 34mg/dL, a potassium of 5.2mmol/L and CO2 of 19mmol/L. The patient was felt 
to have been volume depleted from over-diuresis. The patient's serum creatinine level was 3.2mg/dL, with an 
eGFR of 15mL/minute, on May 2, 2020. A metabolic panel was not repeated on May 3, 2020. On May 4, 2020, 
the serum creatinine level was 2.8mg/dL with an eGFR of 21mL/minute; on May 5, 2020, the serum creatinine 
level was 2.7mg/dL with an eGFR of 22mL/minute. The review has determined that the documentation does 
not support the billed principal and billed secondary diagnosis codes.
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital care provided from May 4, 2020, through May 5, 2020, as billed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 16, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately payable.
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid.
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided
that the Plan does not have to pay for the laboratory services rendered on June 16, 2021.