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

 
We decided that the Plan does not have to pay for the muscle and/or fascia debridement (11043) rendered by 
the out-of-network (OON) provider on October 6, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the muscle and/or fascia debridement (11043) rendered by the out-of-network (OON) 
provider on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist office visits provided from May 17, 2021, to June
7, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the specialist office visits. You say that these claims should have been paid. The
Plan denied your request. The Plan says there was no prior authorization or referral from an in-network
provider to see an out-of-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for specialist office visits provided from May 17,
2021, to June 7, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
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 have seen this provider prior and 
did not know the referral was denied. The Plan denied your request. The Plan says there is no valid referral to 
see an out-of-network provider and your primary care physician must give approval first. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a liver biopsy procedure performed on 
August 10, 2021. 
 
You asked the Plan to waive the copayment for the biopsy. You say that you feel that a needle biopsy is 
different than a surgical one and the copayment should be for a diagnostic procedure. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
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 each outpatient surgery at a hospital outpatient facility.  
 
You have been asked to pay a $325 copayment for the biopsy. Please note that any procedure involving the 
removal of tissue is considered surgical. Therefore, the biopsy 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 a liver biopsy procedure performed on August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat lift chair. 
 
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your 
request. The Plan says a power seat lift chair can only be approved if it is medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 chair. Our reviewer says that the 
requested chair is not medically reasonable or necessary. Our physician reviewer found the request exceeds 
your medical need, as you are able to transfer with bilateral upper extremity support. 
 
 
 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 chair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power seat lift chair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a catheter insertion procedure performed on 
October 6, 2021. 
 
You asked the Plan to waive the copayment for the catheter insertion. You say that you do not understand why 
you had a copayment for the procedure. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
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 $295 
copayment for surgery or other services provided at an outpatient hospital.  
 
 
 You have been asked to pay a $295 copayment for the catheter insertion. The catheter insertion is considered a 
surgical procedure, and therefore 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 a catheter insertion procedure performed on October 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
September 22, 2021, to September 24, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be 
covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 
provided. 
 
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 $250 
copayment per day for days 1-5 of Inpatient hospital care.  
 
 
 You have been asked to pay a $500 copayment for two days of inpatient hospital care ($250 x 2 = $500). 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 inpatient hospital care provided from September 22, 2021, 
to September 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (43239) 
provided on October 27, 2021. 
 
You asked the Plan to waive the copayment for the esophagogastroduodenoscopy. You say that the services 
should be covered as you were told there would be a $20 copayment. The Plan denied your request. The Plan 
says the cost-sharing applied correctly based on the services provided. 
 
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 $250 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 You have been asked to pay a $250 copayment for an esophagogastroduodenoscopy. The 
esophagogastroduodenoscopy 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 an esophagogastroduodenoscopy (43239) provided on October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve to pre-approve a transport wheelchair.
You asked the Plan to pre-approve a transport wheelchair. You say that this equipment is medically necessary.
The Plan denied your request. The Plan says the medical records from your provider confirm you currently
have a manual wheelchair for use in your home. There is no indication from your physician that this equipment
is not functional or needs repair. The requested transport chair would be duplicate equipment.
The Plan must follow Medicare rules. The rules say if equipment serves the same purpose as equipment already
available to an enrollee, it is not considered reasonable and necessary. Medicare does not cover equipment for
use outside of the home. The file shows that you have a manual wheelchair. This equipment serves the same
purpose as a transport wheelchair. Therefore, we decided that the Plan does not have to pre-approve to a
transport wheelchair.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visits and various services received from September 6, 2021,
to September 27, 2021.
You asked the Plan to pay for the services. You say that you thought that this would be covered. The Plan
denied your request. The Plan says that this was billed with the incorrect modifier.
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 stated that there was a valid authorization for the claim, and
overturned the majority of the claim, except for Current Procedural Terminology (CPT) code 73630. The plan
did not provide any notice that only certain services would be authorized. Therefore, the enrollee should be
held harmless for these services. The enrollee should not be held liable for the authorized provider reported the
services with the incorrect modifier. Therefore, we decided that the Plan has to pay for the office visits and
various services received from September 6, 2021, to September 27, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for services provided on June 17, 2021. 
You asked the Plan to pay for the services provided. You say that there has been a misinterpretation of the 
guidelines. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and the rules. The claim lists a place of service as an independent laboratory. The records 
do not show that the specimen was obtained at an independent laboratory. The records also show that the 
specimen at issue was collected on June 9, 2021, not June 17, 2021. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab testing billed for services provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
June 17, 2021.  
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 out of network physician services provided to the 
enrollee on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services provided on June 25, 2021, by an out-ofnetwork (OON) provider.
You asked the Plan to pay for telehealth services. You say that you would like this claim reprocessed for
medical necessity. 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 will never pay for telehealth services provided by an OON provider.
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 telehealth services provided on June 25, 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 Hereditary Cardio Screen panel of 117 genes provided on
March 25, 2021.
You asked the Plan to pay for the Hereditary Cardio Screen panel. You say that there are many studies showing
that this testing is necessary for the patient's condition. The Plan denied your request. The Plan says the order
for this test dated March 17, 2021, is noted as signed by a provider. However, review of claims information
reveals that you were not seen in this provider's office in that time frame. Outreach to the office did not find
documentation for ordering of this lab test. Thus, the medical record and a direct discussion with the
physicians' office do not document any recommendation for this testing.
The Plan must follow Medicare rules. Medicare rules say that genetic testing for hereditary cardiovascular
disease will be considered medically reasonable and necessary only for certain patients for certain genes, which
have been validated by independent organizations. It is noted that there are no current genes which meet the
criteria of the LCD. Based on this information, we decided that Medicare rules for coverage of the Hereditary
Cardio Screen panel have not been met. Therefore, we decided that the Plan does not have to pay for the
Hereditary Cardio Screen panel of 117 genes provided on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve battery backup (E1399) for CPAP machine.
You asked the Plan to pre-approve battery backup. You say that you want to appeal the denial of the battery
backup for your CPAP machine because you have been dealing with problems with the electrical power system
in your home for a long time. The Plan denied your request. The Plan says this item is not covered by Medicare
or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve battery backup (E1399) for CPAP machine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from February 15, 
2021, to February 19, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
services cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in 
the medical record. Specifically, the records do not document the amount of time spent for this service. Based 
on this information, we decided that Medicare rules for coverage of the services provided have not been met. 
 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
In this case, the CPT Code Manual definition of code 20103 is exploration of penetrating wound (separate 
procedure), extremity. We find that CPT code 20103 is not supported in the medical record. The medical 
records provided do not show that the service billed was a distinct procedural service. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital services provided from February 15, 2021, to February 19, 
2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychosocial rehabilitation services (H2017) provided on
July 26, 2021 to September 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychiatric services. You say that the medical records provided will show
proof of medical necessity. The Plan denied your request. The Plan says enrollee's 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. CPT code
H2017 also is not an approved telehealth service code.
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. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
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 psychosocial rehabilitation services (H2017)
provided on July 26, 2021 to September 30, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit (99204) and a visual field
examination (92081) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a specialist office visit and a visual field examination. You say that the
requested provider has been recommended by several friends. The Plan denied your request. The Plan says
there are 14 in-network providers listed within 30 miles of the member's home address. The Plan also says
there was no documentation to why an in-network cannot treat the member's symptoms.
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 (99204) and a visual field examination (92081) to be provided by an out-of-network
(OON) provider.