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

 
We decided that the Plan does not have to pay for additional magnetic resonance imaging (MRI) services 
provided to the enrollee on January 18, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no evidence that additional services were rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT codes 70553 and 70543 are not supported in the medical record. Specifically, the codes have 
already been paid for, and there is no evidence that multiple exams for each code were rendered in this case. 
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 additional magnetic resonance imaging (MRI) 
services provided to the enrollee on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided from June 18, 2021, to 
August 27, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request.  The Plan says a licensed acupuncturist is a non-covered provider type, and the provider is not supervised by 
any physician, physician assistant, nurse practitioner, or a clinical nurse specialist. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, a licensed acupuncturist is a non-covered provider 
type, and the provider is not supervised by any physician, physician assistant, nurse practitioner, or a clinical 
nurse specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided 
from June 18, 2021, to August 27, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the initial hospital care rendered on March 10, 2021. 
 
You asked the Plan to pay for these services. You say that you would like the claim reprocessed. The Plan 
denied your request. The Plan says that procedure code 99221 is not separately payable. 
 
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 states that code 99221 is not separately payable due to 
incidental/mutually exclusive Medicare National Correct Coding Initiatives (NCCI) edits; however, the file 
does not show that the code was billed with another mutually exclusive code. The Plan has not provided any 
documentation or Medicare rules to support that the code is not payable as billed. Therefore, we decided that 
the Plan has to pay for the initial hospital care rendered on March 10, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a sensor (K0553) for a continuous glucose monitor (CGM) 
provided on February 20, 2022. 
 
You asked the Plan to pay for a CGM sensor. You say that the requested item was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the patients medical record adequately supports the medical necessity for the item.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical records do not discuss the item at issue. 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 a sensor (K0553) for a continuous glucose monitor (CGM) provided on February 
20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae Epilepsy Panel provided on January 19, 2022. 
 
You asked the Plan to pay for the Invitae Epilepsy Panel. You say that you feel that this was incorrectly denied. 
The Plan denied your request. The Plan says the treating physician requested authorization for this testing 
which was denied on December 31, 2021. The testing was performed in spite of this denial. On appeal review, 
it was found that this testing was correctly denied as not covered by Medicare. 
 
Medicare rules say that molecular diagnostic laboratory tests such as the Invitae Epilepsy Panel are subject to 
the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and unique test identifier. 
 
 
 We looked at the file and Medicare rules. Review of the DEXTM Diagnostics Exchange shows that this panel is 
not covered by Medicare after review by the MolDX program. Based on this information, we decided that 
Medicare rules for coverage of the Invitae Epilepsy Panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the Invitae Epilepsy Panel provided on January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) reader (K0554) and 
sensor (K0553) provided on December 27, 2021. 
 
You asked the Plan to pay for a CGM and sensor. You say that the requested items were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the patients medical record adequately supports the medical necessity for the item.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The available medical records do not discuss the items at issue. Therefore, we decided that the Plan 
does not have to pay for a continuous glucose monitor (CGM) reader (K0554) and sensor (K0553) provided on 
December 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on November 18, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and the services were rendered in good faith out of medical necessity. The Plan denied your 
request. The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home health visit provided on November 18, 
2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the OTC items provided on December 24, 2021. 
 
You asked the Plan to reimburse you for OTC items. You say that you did not have an active OTC card at the 
time of this purchase and the pharmacy in your nursing home didnt carry the items so they had to be purchases 
at a retail store. The Plan denied your request. The Plan says the OTC items were purchased from a non-
approved Plan vendor. Per your Evidence of Coverage, your over-the counter benefit can only be used to 
purchase items from the OTC catalog supplied by the Plan approved vendor. Also, on December 24, 2021 your 
balance on your OTC card was $0 due to a previous purchase on December 2, 2021 for $50. 
 
The Plan contract covers a supplemental OTC benefit. The Plan contract says your Plan provides $50 every 
calendar quarter for the purchase of covered over-the-counter (OTC) items such as bandages and toothbrushes. 
Your over-the-counter benefit can only be used to purchase items from the OTC catalog supplied by the Plan 
approved vendor. 
 
 We looked at the file and the Plans rules. The file shows that the OTC items were not purchased from the OTC 
catalog or by the Plan approved vendor. Also, the balance on your OTC card was $0 on this date of purchase. 
Based on this information, we decided that the Plans rules for coverage of OTC items have not been met. 
Therefore, we decided that the Plan does not have to reimburse you for the OTC items provided on  
December 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 heavy duty power wheelchair with multiple 
power options (K0862) and accessories. 
 
You asked the Plan to pre-approve a Group 3 heavy duty power wheelchair. You say that the requested Group 
3 heavy duty power wheelchair is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for the requested Group 3 heavy duty power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity.  
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 heavy duty power wheelchair with multiple power options (K0862) and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee has been seeing this provider for years. 
The Plan denied your request. The Plan says the services were provided out-of-network and was 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 office visit provided on January 17, 2022, by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 care. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found you do not have documented skilled 
nursing needs or skilled therapy needs. You are unable and unwilling to participate in daily skilled therapy.  
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 16, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is an inappropriate place of service for a physician interpretation, per Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 85060 is "Blood smear, peripheral, interpretation by 
physician with written report." 
 
It is inappropriate to bill CPT 85060 in an outpatient hospital setting. No payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients. The physician interpretation is paid through the 
clinical laboratory fee schedule payment for the clinical laboratory test. 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 laboratory services provided to the enrollee on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatment to be provided by the requested 
provider. 
 
You asked the Plan to pre-approve the acupuncture treatment. You say that you would like to continue seeing 
this provider because of the benefit that you are getting. The Plan denied your request. The Plan says the office 
of this provider stated that she practices independently and does not work under the supervision or direction of 
a physician, PA, or NP/clinical nurse specialist. 
 
The Plan must follow Medicare rules. The rules say that these treatments may be provided by a physician in 
accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and 
auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture 
must be under the appropriate level of supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, there is no documentation that the acupuncture 
treatment at issue in this appeal meets the Medicare coverage criteria. The provided records do not document 
that the acupuncturist in this case was under the appropriate level of supervision of a physician, PA, or 
NP/CNS. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatment to be 
provided by the requested provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the durable medical equipment (DME) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve DME. You say that any other company would take over 6 months before the 
enrollee would receive their wheelchair The Plan denied your request. The Plan says the services have been 
requested out-of-network. Network providers are available to provide 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 
the durable medical equipment (DME) to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of the ankle provided on October 18, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that the patient cannot choose the radiologist that reads their 
diagnostic tests. The Plan denied your request. The Plan says unauthorized, non-plan 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. 
 
Neither the provider of service nor the referring provider in this case is 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 x-ray of the ankle provided on October 18, 2021 by an out-of-network 
(OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of the cervical spine for the 
enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is needed to give the most appropriate surgical 
recommendation for the enrollee. The Plan denied your request. The Plan says that this is not medically 
necessary. 
 
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 the scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found magnetic resonance 
imaging (MRI) does not allow for hardware and screw evaluation, but is rather a better test for soft tissues. 
Plain films are inadequate for screw placement analysis; thus, the requested CT scan of the cervical spine is 
reasonable and should be approved for this patient who is a candidate for another surgery. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) scan of the cervical spine for the enrollee.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip x-ray exam provided on September 22, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the x-ray exam. You say that the enrollee cannot choose what radiologist reads 
their diagnostic tests. The Plan denied your request. The Plan says the services were provided out-of-network 
and was 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 hip x-ray exam provided on September 22, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the covid 19 test provided on January 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the covid 19 test. You say that this service has been paid for by the plan in the 
past. The Plan denied your request. The Plan says the service was provided out-of-network and was 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 covid 19 test provided on January 15, 2022, by 
an out-of-network (OON) provider.