Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311) for a 
power wheelchair. 
 
You asked the Plan to pre-approve the expandable controller. You say that the expandable controller is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when 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 the expandable controller. Our reviewer says that the expandable controller is not medically necessary. Our physician reviewer found the requested 
accessories are not medically necessary as the enrollee does have use of her hands and can operate and control 
the power options using the switches that are included in the basic wheelchair. 
 
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 expandable controller have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pre-approve dental services to be provided by a contracted provider.  You asked the Plan to pre-approve dental services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the dental services requested are not a covered benefit.  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. The Plan has failed to provide a 2022 Preventative and Comprehensive Dental Coverage handbook. Therefore, we decided that the Plan has to pre-approve dental services to be provided by a contracted provider.  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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need care in the SNF, and any delay could 
cause health issues or injury. You say that you do not have the strength to take care of yourself. The Plan 
denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the 
services required can safely be received at a different setting. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that the 
enrollee requires skilled nursing services. The medical records do support that skilled therapy services, 
however they are not required on a daily basis. Although the enrollee is very limited functionally, the provided 
records do not document a significant decline in the enrollee's functional status compared to her recent baseline 
to necessitate daily inpatient skilled therapy services. There is no documentation that the enrollee requires the 
necessary services on an inpatient basis, only in a skilled nursing facility setting. Records do not document that 
services in the home with home health care or in a long-term care facility on a part time basis are not 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection (E2311), and leg rest (E1012). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the items are 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 pre-approve the wheelchair accessories. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does have use of his hands and can operate and control the power options 
using the switches that are included in the basic wheelchair. The documentation does not indicate he meets 
criteria for power elevating leg rests. 
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the electronic connection (E2311), and leg rest (E1012).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the triamcinolone acetonide injection (J3300) provided on 
September 23, 2021. 
 
You asked the Plan to pay for the triamcinolone acetonide injection (J3300). You say that the medical records 
are attached for claim reprocessing. The Plan denied your request. The Plan says the records do not support 80 
units billed of CPT code J3300. 
 
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 J3300 is injection, triamcinolone acetonide, preservative 
free, 1 mg. 
 
  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 triamcinolone acetonide injection (J3300). Our reviewer 
says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the units would be billed by 1 mg, which would be 40 units. In this case, 80 units cannot be verified. 
 
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 triamcinolone acetonide injection (J3300) have not been met. Therefore, we 
decided that the Plan does not have to pay for the triamcinolone acetonide injection (J3300) provided on 
September 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs or documented skilled therapy needs. Your care needs, custodial and intermittent, can, as a practical 
matter, be provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical intraoral x-rays (D0220 and D0230) provided 
on November 18, 2021. 
 
You asked the Plan to pay for the periapical intraoral x-rays. You say that you would like reconsideration 
because you were not aware that these services would not be covered. The Plan denied your request. The Plan 
says these x-rays are not listed as a covered benefit under your contract. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periapical intraoral x-rays (D0220 and D0230) provided on November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GTC hereditary profile (81455) provided on December 23, 
2020 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that molecular testing was requested directly 
from the treating physician who makes the professional determination of diagnosis and medical necessity to 
successfully treat the enrollee. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 GTC hereditary profile (81455) provided on 
December 23, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on February 
12, 2021, to October 29, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendering dentist 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 dental 
services provided by an opt-out provider on February 12, 2021, to October 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 2, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.   
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on February 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavioral assessment (96127) provided on November 
16, 2021. 
 
You asked the Plan to pay for the behavioral assessment (96127). You say that you were informed the doctor 
was in-network and authorization would not be needed. You say that you would not have gone ahead with this 
patient if you were properly informed, and you are requesting payment. The Plan denied your request. The Plan 
says procedure codes 90791 and 90834 have been approved. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 96127 
is a column II code to column I code 90791. This claim cannot be billed with a modifier to bypass the edit. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for the behavioral assessment (96127) provided on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic casts (D0470), and 2D oral/facial photographic 
imaging (D0350) provided by a participating provider on July 30, 2021. 
 
You asked the Plan to pay for diagnostic casts and 2D oral/facial photographic imaging. You say that you 
would like the Plan to pay for this. The Plan denied your request. The Plan says D0470 and D0350 are not 
covered dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for diagnostic 
casts (D0470), and 2D oral/facial photographic imaging (D0350) provided by a participating provider on July 
30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on January 
16, 2021, February 10, 2021, February 16, 2021, and July 16, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the DME. You say that you would like reconsideration for the claims. The Plan 
denied your request. The Plan says the rendering provider is an out-of-network 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 durable medical equipment (DME) provided 
on January 16, 2021, February 10, 2021, February 16, 2021, and July 16, 2021, by an out-of-network (OON) 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) 
services provided on September 2, 2021, and November 5, 2021. 
 
You asked the Plan to waive the copayment for the MRI services. You say that you were not aware of any 
additional cost share for the imaging services you received. The Plan denied your request. The Plan says the 
cost shares have processed correctly for these claims. 
 
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 $50 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.   
You have been asked to pay a $50 copayment for each of the MRIs you received. This care 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 the magnetic resonance imaging (MRI) services provided on September 2, 2021, 
and November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for An office visit provided on September 17, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for An office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
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 September 17, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services (A0427, A0425) 
provided on October 22, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the correct diagnoses were submitted with 
this claim. The Plan denied your request. The Plan says the diagnosis codes billed for this claim cannot be 
billed together per Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that the ambulance services are not supported in the medical record. Specifically, this claim was billed 
with diagnosis codes J96.00 and R06.2. Diagnosis code R06.2 has a type 1 Excludes note indicating that R06.2 
and J96.00 cannot be billed together. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the 
ambulance transportation services (A0427, A0425) provided on October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for hyperbaric oxygen therapy provided from 
March 1, 2021, to August 31, 2021. 
 
You asked the Plan to waive the coinsurance for hyperbaric oxygen therapy. You say that you have never 
gotten a bill for a copay in all the treatments you have received. The Plan denied your request. The Plan says 
the coinsurance was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 10% 
coinsurance for each in-network Medicare-covered other diagnostic test.  
 
 
  You have been asked to pay only a total of $500 for hyperbaric oxygen therapy services.   
 
Date of Service Service Allowed 
Amount 
Standard Cost Member Liability 
March 1, 2021 Hyperbaric Oxygen Therapy $528.19 10% ($52.82) $50.00 
March 2, 2021 Hyperbaric Oxygen Therapy $528.19 10% ($52.82) $50.00 
March 3, 2021 Hyperbaric Oxygen Therapy $528.19 10% ($52.82) $50.00 
March 4, 2021 Hyperbaric Oxygen Therapy $528.19 10% ($52.82) $50.00 
March 5, 2021 Hyperbaric Oxygen Therapy $528.19 10% ($52.82) $50.00 
March 8, 2021 Hyperbaric Oxygen Therapy $528.19 10% ($52.82) $50.00 
August 26, 2021 Hyperbaric Oxygen Therapy $528.19 10% ($52.82) $50.00 
August 27, 2021 Hyperbaric Oxygen Therapy $528.19 10% ($52.82) $50.00 
August 30, 2021 Hyperbaric Oxygen Therapy $528.19 10% ($52.82) $50.00 
August 31, 2021 Hyperbaric Oxygen Therapy $528.19 10% ($52.82) $50.00 
Total:    $528.20 $500 
 
Hyperbaric oxygen therapy 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 coinsurance for hyperbaric oxygen therapy 
services provided from March 1, 2021, to August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy of 105 genes provided on June 
24, 2021. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that there are multiple studies to support 
this type of testing. This was billed correctly and is medically necessary. The Plan denied your request. The 
Plan says Medicare rules require that panels be reported with a single panel code. In addition, the POS code 
reported does not match the location in which the sample was collected. 
 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 Tempus xF liquid biopsy 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 the Tempus xF liquid biopsy of 105 genes provided on June 
24, 2021.