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

 
We decided that the Plan does not have to pay for lab services provided on August 04, 2022. 
 
You asked the Plan to pay for lab services. You say that this was medically necessary and should be covered. 
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 lab services provided on 
August 04, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service October 19, 
2022. 
 You asked the Plan to pay for procedure code 76642. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service October 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biopsy of oral tissue (D7286) and a consultation (D7286) 
provided by an out-of-network provider on October 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that there were no providers in your service area, 
and you had no choice then to see the out-of-network provider. The Plan denied your request. The Plan says the 
biopsy of oral tissue was received from an out-of-network provider and is not covered by your supplemental 
benefits. Also, the denial of payment for the consultation is correct, because it is not covered by the Plan. 
 
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. 
 
  The record shows you received the biopsy of oral tissue from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the biopsy of oral tissue is not covered under this 
benefit when received from an out-of-network provider. The consultation is not covered under the Plan's dental 
benefit. Therefore, we decided that the Plan does not have to pay for biopsy of oral tissue (D7286) and a 
consultation (D7286) provided by an out-of-network provider on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient occupational therapy (OT) services provided 
on April 15, 2021. 
 
You asked the Plan to pay for the OT services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the corrected claim was not submitted timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of the initial determination. 
 
The record shows that a claim for the OT services was not filed until September 27, 2022. This means that 
more than one calendar year from the date of the initial determination. Therefore, we decided that the Plan does 
not have to pay for the outpatient occupational therapy (OT) services provided on April 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 20, 
2022. 
 You asked the Plan to pay for procedure code 76641. You say that the records support multiple procedures on 
this date. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 20, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from January 13, 2021, to 
January 20, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient services. You say that the diagnoses are supported by the 
physician's documentation. The Plan denied your request. The Plan says that the clinical evidence did not 
support the diagnoses. 
 
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. 
 
We looked at the file and the rules. The Plans medical review and case summary indicate medical records 
were provided. However, the medical records used in the Plans decision were not provided in this case. The 
Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request.  Therefore, we decided that the Plan has to pay for the inpatient hospital services 
provided from January 13, 2021, to January 20, 2021, at the Diagnosis Related Group (DRG) originally billed.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee had another fall at home and needs 
additional therapy. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
guidelines for admission to an IRF. 
 
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 does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve the requested services. You say that you will not be able to walk without the 
procedure. The Plan denied your request. The Plan says there is little evidence that this is an appropriate 
procedure for your pain. 
 
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 requested services. Our physician 
reviewer found the enrollee has sacroiliitis. He has had a prior sacroiliac (SI) joint injection which achieved 
50% pain relief. A similar injection in the past also did not achieve a significant pain relief response. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service. The elements of the coverage criteria are not satisfied. Therefore, the requested service is 
not recommended. 
 
 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided from August 22, 
2022, to September 2, 2022. 
 
You asked the Plan to waive the copayment for physical therapy. You say that the cost sharing seems very 
excessive. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $40 copayment for each therapy visit.  
 
The enrollee has been asked to pay $280 ($40/visit x 7 visits = $280) for physical therapy. This item/service 
falls within the outpatient rehabilitation services benefit category. This means that the enrollee has been asked 
to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for physical therapy provided from August 22, 2022, to September 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service July 2, 2022. 
 
You asked the Plan to pay for procedure code 99291. You say that this service is not a duplicate. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. 1 unit of 99291 was already 
paid for this date of service. You billed a second unit of this code, exceeding the MUE. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99291 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99291 billed for date of service 
July 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device, four or more leads (E0730),provided on July 1, 2022. 
 
You asked the Plan to pay for the TENS device leads. You say that the item was medically necessary. The Plan 
denied your request. The Plan says documentation submitted did not include a valid Proof of Delivery (POD), 
or a Delivery Ticket. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The date on the packing slip and delivery slip do not match the date of service. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the transcutaneous electrical nerve stimulation (TENS) device, four or more leads 
(E0730),provided on July 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower limb prosthetics to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve lower limb prosthetics. You say that the enrollee's residual limb has 
decreased in size resulting in the socket being too large. The Plan denied your request. The Plan says this 
provider is out-of-network with the Plan and the needed prosthetics can be obtained from an in-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 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 
lower limb prosthetics 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 biopsy procedure provided on October 
11, 2022. 
 
You asked the Plan to waive the copayment for a biopsy procedure. You say that you recieved a bill for $290 
for a biopsy, it is not a surgery. 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 $290 
copayment for outpatient hospital services. 
 
You have been asked to pay a $290 copayment for a biopsy procedure. This item/service 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 biopsy 
procedure provided on October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (34203, 75710) provided on July 11, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the codes billed are not supported in the records. 
 
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 definitions of codes 34203 & 75710 are embolectomy or thrombectomy, 
with or without catheter, in the popliteal-tibio-peroneal artery, by leg incision and angiography for a unilateral 
extremity with radiological supervision and interpretation. 
 
We find that CPT code 34203 & 75710 is not supported in the medical record. Specifically, the medical records 
provided do not include sufficient documentation to validate that an embolectomy or thrombectomy, with or 
without catheter, in the popliteal-tibio-peroneal artery, by leg incision was performed. Code 75710 has a 
bundled relationship to procedure 37228, which was performed on July 11, 2022. A modifier is allowed to 
unbundle the procedure, providing the medical records support the use of the modifier. In this case, the medical 
records provided does not include sufficient documentation to validate that CPT 75710 was performed as a distinct, separate service. Based on this information, we decided that Medicare rules for coverage of the 
surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical 
services (34203, 75710) provided on July 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CTA provided on August 17, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the CTA. You say that this facility was the only facility to read the scan. The 
Plan denied your request. The Plan says you must receive your care from a 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 the CTA provided on August 17, 2022, by OON 
provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 9, 2022, to 
February 7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you were not aware of the policy 
change switching to NOAs and the claim should be reconsidered for payment due to the miscommunication. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
  The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 9, 2022, to 
February 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-spinal bone growth (osteogenesis) stimulator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a bone growth stimulator is covered when 
specific criteria 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted documentation does not 
contain a minimum of two sets of x-rays obtained prior to starting treatment with the bone growth stimulator, 
separated by a minimum of 90 days, each including multiple views of the fracture site with a interpretation by a 
treating practitioner. There is no written interpretation by a treating practitioner stating that there has been no 
clinically significant evidence of fracture healing between the two sets of x-rays. The criteria are not met; 
therefore, the services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a non-spinal bone growth (osteogenesis) stimulator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says criteria for admission to the LTACH have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the medical record does not indicate that the enrollee requires services that are 
not being currently received but that would be available at the LTACH facility.  The elements of the coverage 
rules are not satisfied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.