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

 
We decided that the Plan does not have to pre-approve the dialysis services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the dialysis services. You say that you would like to continue to receive 
services from the OON provider. The Plan denied your request. The Plan says a complete care coordination 
transition from the OON provider to the in-network provider has been completed. Also, the in-network 
provider is within the same service area 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 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 
the dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for an abdominal X-ray (74019) provided on March 17, 2022. 
 
You asked the Plan to pay for an abdominal X-ray. You say that you have provided records to support the 
service at issue. The Plan denied your request. The Plan says that rules for payment have not been met because 
the service at issue is included in another billed 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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has denied this service stating that payment for procedure 
code 74019 is included in the payment of code 74022. The Plan has not forwarded any evidence that code 
74022 was billed on the same date of service. The Plan has not provided additional evidence to indicate why 
code 74019 cannot be paid. It is the burden of the Health Plan to substantiate their denial with evidence. In this 
case, the Plans denial is not substantiated, so we must find in your favor. Therefore, we decided that the Plan 
has to pay for an abdominal X-ray (74019) provided on March 17, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the female external urinary collection device; pouch (A4328) 
purchased December 2, 2021 to December 29, 2021. 
 
You asked the Plan to pay for the female external urinary collection device. You say that the enrollee has 
incontinence and the PureWick system is a must for her care. You are appealing the denial for partial 
reimbursement. The Plan denied your request. The Plan says the durable medical equipment was purchased 
from a provider that is not certified for Medicare. If you go to a provider who is not eligible to participate in 
Medicare, you will be responsible for the full cost of the services you receive. 
 
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. 
 
 
 
 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the female external urinary collection 
device; pouch (A4328) purchased December 2, 2021 to December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481) provided September 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary. The Plan denied 
your request. The Plan says this procedure 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 lab services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the medical literature and clinical practice guidelines does not support the clinical utility of multiplex 
PCR panels in the diagnostic work-up of pressure ulcers. Standard of care is well documented to consist of 
standard culture techniques for the pathogen of concern. 
 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 lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (87481) provided September 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says the long term acute care hospital (LTACH) 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 patient requires additional acute care services that can safely be completed at the 
current facility until more appropriate for a lower level of care after additional weaning trials are made. The 
patient does not require services at the LTACH that are not already available at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dialysis services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the dialysis services. You say that you would like to receive services from 
the OON provider. The Plan denied your request. The Plan says a complete care coordination transition from 
the OON provider to the in-network provider has been completed. Also, the in-network provider is within the 
same service area 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 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 
the dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on January 13, 
2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on January 13, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve PET scan. You say that it is medically necessary for the enrollee to get a 
PET scan for surgical preparation. The Plan denied your request. The Plan says that the denial of authorization 
for this service is correct, because this is being requested for an unsupported use. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 PET scan. Our reviewer says that the 
enrollee meets the Medicare criteria for the requested PET scan. Our physician reviewer found the enrollee has 
biopsy-proven scalp melanoma, and the treating physician documented that PET computed tomography (PET-
CT) is necessary to determine whether sentinel lymph node biopsy or neck dissection would be warranted. In 
this case, the PET-CT would aid in determining the type and extent of the proposed invasive diagnostic 
procedure. Consequently, this is 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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) scan.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services (T1019). 
 
You asked the Plan to pre-approve personal care services. You say that it would benefit the enrollee to have a 
caregiver in their residence at all times due to their health. The Plan denied your request. The Plan says 
personal care services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of personal care services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal 
care services (T1019).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty rollator walker (E0143, E0149, E0156). 
 
You asked the Plan to pre-approve the walker. You say that this is medically necessary. The Plan denied your 
request. The Plan says the weight requirements are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty walker is covered for enrollees who 
weigh more than 300 pounds. 
 
You are under the weight requirement for this request at 250 pounds. Based on this information, we decided 
that Medicare rules for coverage of the walker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a heavy duty rollator walker (E0143, E0149, E0156).
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 appealing the denial of LTACH 
admission.  The Plan denied your request. The Plan says you are receiving appropriate inpatient acute care and 
are currently unstable for transfer to an LTACH. 
 
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 you were admitted to the acute care hospital with respiratory distress related to 
localized squamous cell carcinoma of the hypopharyngeal area complicated by pneumothorax, emphysema, 
pulmonary nodules and requiring trach and percutaneous endoscopic gastrostomy placement. Chemoradiation 
treatment was given. You were treated with antibiotics, blood transfusion, and breathing treatments.  
 
 
 Recent notes describe you as recently tolerating low dose oxygen via nasal cannula and tolerating tube feeds 
however, you had a recent aspiration event requiring restarting of antibiotics and increase oxygen 
requirements. You appear to be currently unstable and should only require short-term additional acute care 
services that can safely be completed at the current facility until more stable and appropriate for a lower 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 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 lab services (83540, 83550, 85045) provided January 19, 
2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
lab services (83540, 83550, 85045) provided January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82728, 83540, 83550) provided January 24, 
2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
lab services (82728, 83540, 83550) provided January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you would like to receive the 
services from an OON provider. The Plan denied your request. The Plan says the requested provider is an OON 
provider and there are multiple in-network providers who provide the same quality of service. Also, the Plan 
has already approved an in-network provider for the enrollee to see. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the attendant care services (S5125) provided on October 13, 
2021. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as 
it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the attendant care services (S5125) provided on October 13, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 29, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the attendant care services provided on October 14, 2021. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the attendant care services provided on October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment shoe inserts 
provided on December 2, 2021. 
 
You asked the Plan to waive the coinsurance for DME shoe inserts. You say that you should not have to pay 
for this coinsurance. The Plan denied your request. The Plan says the coinsurance applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME). The allowed amount of the DME is $329.18 resulting in a 
coinsurance amount of $65.82 ($329.18 x 20% = $65.82). 
 
You have been asked to pay a $65.82 coinsurance for DME shoe inserts. DME shoe inserts falls within the 
Durable Medical Equipment (DME) 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 
durable medical equipment (DME) shoe inserts provided on December 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on March 2, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that a trip to an 
emergency room by ambulance or private vehicle would have been unnecessary. The Plan denied your request. 
The Plan says you received non-transport ambulance services, and this claim denied correctly. 
 
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 March 2, 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 with no 
transport (A0998) provided on March 2, 2022.