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

 
We decided that the Plan does not have to pay for the routine foot care rendered on November 16, 2020. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
 
 
 
 
 
 
 
 Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the routine foot care 
rendered on November 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that these are medically necessary. The 
Plan denied your request. The Plan says that this is a non-covered item. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for laboratory services, imaging, and an office 
visit provided on June 22, 2021. 
 
You asked the Plan to waive the copayments for lab services, imaging, and an office visit. You say that these 
charges should be covered. The Plan denied your request. The Plan says the copayments applied are 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 $35 
copayment for an x-ray, echocardiogram (ECG), and office visit and a $5 copayment for lab work.   
You have been asked to pay a total of $80 copayment for lab services, imaging, and an office visit. Lab 
services, and imaging falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category.  The office visit falls within the Physician/Practitioner Services, Including Doctor's Office 
Visits 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 copayments for laboratory services, imaging, 
and an office visit provided on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99308) provided on January 6, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that it was the responsibility of the hospital 
staff to obtain prior authorization. The Plan denied your request. The Plan says the services were provided out-
of-network and were not approved in advance. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the nursing facility care (99308) provided on 
January 6, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail debridement (11720) provided on January 11, 2022. 
 
You asked the Plan to pay for nail debridement (11720). You say that the medical records support the services 
billed and the claim should be reprocessed. The Plan denied your request. The Plan says procedure code 11720 
remains denied because it is mutually exclusive to procedure code 11056. 
  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 11720 is a column II code to column I code 11056; however, 11720 
was billed with a modifier.  
 
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 nail debridement (11720). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
procedure report describes debridement and paring or cutting of nails. In this case, debridement would be 
considered inclusive to cutting or pairing services performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nail debridement (11720) have not been met. Therefore, we decided that the 
Plan does not have to pay for nail debridement (11720) provided on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve RFA to the SI joint (CPT code 64625). 
 
You asked the Plan to pre-approve the service. You say that you have a very crooked lumbar area that causes a 
lot of pain. You state that you have already had one ablation in one area that relieved a lot of pain and now you 
need another ablation to relieve the rest of the pain. The Plan denied your request. The Plan says the clinical 
value and effectiveness of radiofrequency ablation to the SI joint in the setting of SI dysfunction have not been 
demonstrated in the peer-reviewed literature. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found studies completed say that this procedure does not improve outcomes compared to standard 
treatment of SI joint pain. RFA for denervation, whether performed using traditional, cooled, or pulsed 
radiofrequency, is considered investigational and therefore, not medically 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve RFA to the SI joint (CPT code 64625).
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 SNF care. The Plan denied your 
request. The Plan says rules for SNF care have not been met. 
 
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 that the medical records do not 
document that you require services on an inpatient basis, only in a skilled nursing 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 21, 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 the provider is out-of-network and authorization is 
required prior to 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 21, 2021, by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says based on Medicare guidelines, the requested SNF services do not meet the requirements for 
approval. 
 
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 SNF 
care is not medically reasonable and necessary. Our physician reviewer found that you do not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You 
do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) setting. 
 
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 a skilled nursing facility (SNF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto. 
 
You asked the Plan to pre-approve Xarelto. You say that the enrollee was previously on Coumadin with 
decreased quality of life, and transitioned to Xarelto. The Plan denied your request. The Plan says Xarelto is a 
self-administered drug, and does not fall under Part B Coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xarelto.  
 
 
 
 Benefits for Xarelto may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mental health visit provided on May 6, 
2020. 
 
You asked the Plan to waive the copayment for mental health visit. You say that you thought this has a $0 
copayment. The Plan denied your request. The Plan says the copayment applied is 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 $30 
copayment for each Medicare- covered individual or group therapy visit.  
 
You have been asked to pay $30 copayment for mental health visit. Mental health visits fall within the 
Outpatient Mental Health Care 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 
mental health visit provided on May 6, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have trouble walking and need physical therapy 
and occupational therapy to regain strength. The Plan denied your request. The Plan says that based on 
Medicare guidelines, the requested IRF services do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that Parkinson's disease is an IRF compliant diagnosis. Clinical documentation shows that you would 
benefit from being evaluated by a physical medicine and rehabilitation physician at least three times per week 
on an inpatient basis. Evaluating therapists state that you would benefit and be able to tolerate intense therapy, 
thus criteria have been fulfilled. IRF care is medically appropriate 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on August 27, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
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 ophthalmological services provided on August 27, 
2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $27.09 coinsurance for an ankle foot orthosis received on 
September 9, 2021. 
 
You asked the Plan to waive the $27.09 coinsurance for an ankle foot orthosis. You say that you were told 
there would be no coinsurance for the orthosis. The Plan denied your request. The Plan says you pay a 20% 
coinsurance for an ankle foot orthosis. 
 
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 $27.09 
coinsurance for Prosthetic Devices and Related Supplies.  
 
You have been asked to pay a $27.09 coinsurance for an ankle foot orthosis. An ankle foot orthosis falls within 
the Prosthetic Devices and Related 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 $27.09 
coinsurance for an ankle foot orthosis received on September 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammography provided on 
March 3, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic mammography. You say that you received a 
regular mammogram and do not know why you were charged a copayment. The Plan denied your request. The 
Plan says the proper copayment was applied for the service that was rendered. 
 
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 Diagnostic procedures and tests in a Specialists office.  
 
  You have been asked to pay a $35 copayment for the diagnostic mammography. The diagnostic mammography 
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 a diagnostic mammography provided on March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit under outpatient hospital 
observation provided on February 11, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit under outpatient hospital observation. You say 
that you should not have this copayment while under observation. The Plan denied your request. The Plan says 
the copayment 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 $30 
copayment for a specialist visit under outpatient hospital services.  
 
You have been asked to pay a $30 copayment for a specialist visit under outpatient hospital observation. A 
specialist visit under outpatient hospital observation falls within the Outpatient Hospital Services 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 specialist visit under outpatient hospital 
observation provided on February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 17, 2021 billed with 
codes 81227, 81230, 81240 81241, 81335, 81346 81355, and 81408. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 17, 2021 billed with codes 81227, 81230, 81240 81241, 81335, 81346 81355, and 81408.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), ground mileage (A0425), and life sustaining supplies (A0422) provided on January 20, 
2022. 
 
You asked the Plan to pay for the ambulance services. You say that the services should be covered. The Plan 
denied your request. The Plan says the ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found the documentation 
does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other 
type of vehicle) were contraindicated for the enrollee on January 20, 2022. The reviewer found that the 
documentation does not support that the enrollee needed the expertise, services and lifesaving and life-
sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The reviewer also 
found that the documentation does not support that the ambulance transport on January 20, 2022, was 
medically reasonable and necessary. Therefore, the reviewer found that the ambulance services were not 
medically reasonable or 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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), ground 
mileage (A0425), and life sustaining supplies (A0422) provided on January 20, 2022.