Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT), thorax, diagnostic 
(71260) and computed tomography (CT), abdomen and pelvis (74177). 
 
You asked the Plan to pre-approve a CT scan of the thorax, abdomen, and pelvis. You say that the CT scan is 
medically necessary. The Plan denied your request. The Plan says the request cannot be approved because the 
records do not show results of a chest x-ray taken after the enrollee's symptoms started or changed that were 
assessed by a radiologist. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 a CT scan of the thorax, abdomen, and 
pelvis. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee 
is an 80-year-old male with hyponatremia. He had a CT angiogram in Dec 2022, revealing no mass. In March 
2023, CT thorax was requested looking for mass again. However, the provided records did not show report of a 
recent CXR which is standard of care for looking for a mass prior to considering advanced imaging. There was 
no other clinical documentation supporting use of CT thorax at this time. Therefore, this request for such will 
be considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the thorax, abdomen, and pelvis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a computed tomography (CT), thorax, diagnostic (71260) 
and computed tomography (CT), abdomen and pelvis (74177).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic testing provided to the enrollee on February 8, 2022.
You asked the Plan to pay for the diagnostic testing. You say that these services were medically necessary. The Plan denied your request. The Plan says that the Plan pays for these services when the facility where the services were provided bills the Plan.
The plan follows Medicare rules. Medicare rules say that when services are provided by a mobile unit, the mobile unit should bill the POS as the entity that is being served.
Under Medicare rules, you should have billed POS 22-On Campus-Outpatient Hospital. Instead, you billed POS 15-Mobile Unit. This is not appropriate. Therefore, we decided that the Plan does not have to pay for the diagnostic testing provided to the enrollee on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for a consultation - diagnostic service 
provided by dentist or physician (D9310) provided on November 28, 2022. 
 
You asked the Plan to waive the cost-sharing for the consultation. You say that you were informed by the Plan 
you would not be charged for the consultation. You also say that you are being billed for $101.20 and you do 
not want to pay for this date of service. The Plan denied your request. The Plan says we have reviewed the call 
logs, and we were unable to substantiate that you were misquoted. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 30% 
coinsurance after $100 deductible for comprehensive dental services.  
 You have been asked to pay a 30% coinsurance after the $100 deductible for the consultation. This service falls 
within the comprehensive dental 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 cost-sharing 
for a consultation - diagnostic service provided by dentist or physician (D9310) provided on November 28, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy testing. 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. You say that this testing is medically 
necessary. The Plan denied your request. The Plan says this is not an accepted standard of medical practice for 
the enrollee's diagnosis. 
 
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 bioimpedance spectroscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found devices using bioimpedance spectroscopy are considered investigational 
for use in the diagnosis, surveillance, or treatment of enrollees with lymphedema including use in subclinical 
secondary lymphedema.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedance spectroscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bioimpedance spectroscopy testing.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 13, 2022, to May 12, 2022.

You asked the Plan to pay for the home health services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says the NOA was not received. As such, this final claim was correctly denied.

The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of care date for home health services. NOAs which are received more than 30 days from the timely filing date result in no payment being made for the episode of care. 

In this case, the start of care date is March 14, 2022. The NOA was not received by the Plan. As there is no NOA included in the documentation provided, no payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from April 13, 2022, to May 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on 
December 05, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for outpatient surgery/Medicare-covered surgery or other services provided. 
 
You have been asked to pay a $300 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-covered surgery or other services provided 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 outpatient surgery provided on December 05, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 19, 2022, 
through July 24, 2022. 
 
You asked the Plan to pay for the inpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says they need records to base their decision for the appeal. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient services have been met. 
Specifically, the documentation submitted does not include any medical records. The record shows that the 
Plan requested clinical documentation and did not receive a response. Therefore, we decided that the Plan does 
not have to pay for inpatient hospital services provided on July 19, 2022, through July 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on January 24, 2022. 
 
You asked the Plan to pay for chiropractic services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chiropractic services 
provided on January 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) provided on 
January 05, 2022, to January 21, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF). You say that you disagree with 
the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $2,256 
copayment for skilled nursing facility (SNF). 
 
You have been asked to pay a $2,256 copayment for skilled nursing facility (SNF). This item/service falls 
within the skilled nursing facility (SNF) 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 skilled nursing facility (SNF) provided on January 05, 2022, to January 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to waive the coinsurance for the continuous glucose monitor supplies 
provided on January 05, 2023. 
 
You asked the Plan to waive the coinsurance for the continuous glucose monitor supplies. You say that there is 
a coding issue with this claim. The Plan denied your request. The Plan says this cost sharing was charged 
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 20% 
coinsurance for in-network durable medical equipment. 
 
You have been asked to pay 20% coinsurance for the continuous glucose monitor supplies. This item/service 
falls within the in-network durable medical equipment 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. The total you owe is $51 ($255.01 allowed amount x 20% 
coinsurance = $51). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
continuous glucose monitor supplies provided on January 05, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for pyelonephritis and a fall. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on December 3, 2021, 
through December 27, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that the services should be covered. The 
Plan denied your request. The Plan says this provider 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 the 
psychotherapy services provided on December 3, 2021, through December 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental gradient pressure pneumatic appliance, full leg (E0671) to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve a pneumatic compression device and an appliance. You say that the enrollee 
would face obstacles that would impair healing if he is forced to use the in-network provider. The Plan denied 
your request. The Plan says the enrollee must use network providers to receive services/care. The principal 
reason for prior authorization for OON care is if services cannot be obtained in network. There are in-network 
providers available for this service. 
 
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 pneumatic compression device (E0652) and a segmental gradient pressure pneumatic appliance, full leg 
(E0671) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2019 billed for date of service September 
8, 2022. 
 
You asked the Plan to pay for procedure code H2019. You say that the code is payable by Medicaid. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code H2019 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H2019 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H2019 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H2019 billed for date of service September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on August 21, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The file shows that a comprehensive cancer gene panel was provided. We find that the panel testing was not 
billed with a single code as required. Based on this information, we decided that Medicare rules for coverage of 
the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
testing services provided on August 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
November 02, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this should be a 
screening colonoscopy not a diagnostic colonoscopy. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for in-network outpatient surgery at an outpatient hospital. 
 
You have been asked to pay a $225 copayment for the diagnostic colonoscopy. This item/service falls within 
the in-network outpatient surgery at an outpatient hospital 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. The medical records show you received a 
diagnostic colonoscopy. Therefore, we decided that the Plan does not have to waive the copayment for the 
diagnostic colonoscopy provided on November 02, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
January 05, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were sent to the 
ER unnecessarily by another provider for an x-ray. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for the emergency room visit. This item/service falls within the 
emergency 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 the emergency room visit 
provided on January 05, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that the enrollee is currently suffering from end-
stage chronic obstructive pulmonary disease (COPD), and is hospice. You also say that the enrollee is unable to 
work, struggles to care for themself, and would benefit from the services provided by the Plan. The Plan denied 
your request. The Plan says based on the information submitted there is no documentation that the enrollee 
meets the criteria for coverage. 
 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 is under the Medicare hospice benefit. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).