Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the interpretation of the cardiac blood pool imaging provided on 
February 28, 2022. 
 
You asked the Plan to pay for the cardiac blood pool imaging. You say that you had this testing during your 
hospital stay and feel that this should be covered by the Plan. The Plan denied your request. The Plan says that 
the taxonomy of the rendering provider is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided sufficient evidence to support the denial of payment 
in this case. The Plan has argued that the rendering provider's taxonomy is not covered by Medicare. However, 
we have not been provided with this physician's National Provider Identification (NPI) number to verify the 
taxonomy, nor a copy of the claim to verify the services rendered and the reported taxonomy on the claim. In 
addition, there was no specific Medicare rule cited that prohibits payment for services rendered by the 
taxonomy code at issue. Therefore, we decided that the Plan has to pay for the interpretation of the cardiac 
blood pool imaging provided on February 28, 2022.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for LTACH is correct. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
current acute care hospital. All medically necessary care is being provided in the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care on February 26, 2022. 
 
You asked the Plan to waive the copayment for urgent care. You say that you disagree with the amount being 
charged. The Plan denied your request. The Plan says the cost-sharing you are being charged 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 a $50 
copayment for covered services to a medical facility or urgent care center per visit Urgently needed services. 
Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or 
condition that requires immediate medical care. Urgently needed services may be furnished by network 
providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. 
 
 
 
 
 You have been asked to pay a $50 copayment for urgent care. Urgent care falls within the Urgently needed 
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 urgent care on February 
26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided from December 10, 2021, 
to December 29, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
payable for these services. 
 
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. 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, the provider in question is a licensed acupuncturist. 
The services were not provided under the supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for the 
acupuncture services provided from December 10, 2021, to December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid fitting/checking (V5011) and digital hearing 
aid (V5261) provided on December 22, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aid fitting/checking and digital hearing aid. You say that your 
primary care provider advised you to stick to what is working, which is why you went to this OON provider. 
The Plan denied your request. The Plan says items are to be supplied by the Plan's hearing aid vendor. The Plan 
also says that there is no coverage if hearing aids or related services are received from an OON provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid fitting/checking and digital hearing aid have not been met. Therefore, we decided 
that the Plan does not have to pay for the hearing aid fitting/checking (V5011) and digital hearing aid (V5261) 
provided on December 22, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99214) provided 
on March 30, 2022. 
 
  You asked the Plan to waive the copayment for the outpatient office visit. You say that you had an annual 
routine eye exam, and do not believe you should have to pay a specialist office visit copayment of $40. The 
Plan denied your request. The Plan says the $40 copayment for an outpatient visit for services to diagnose 
and/or treat a disease or condition of the eye applies per your Plan's benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The record shows that you received a medical eye exam, and you are 
responsible for a $40 copayment. Based on this information, we decided that the Plan's rules for coverage of 
the outpatient office visit have not been met. Therefore, we decided that the Plan does not have to waive the 
copayment for the outpatient office visit (99214) provided on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gas permeable hard contact lens (scleral shell) with 
associated fitting. 
 
You asked the Plan to pre-approve the scleral shell and fitting. You say that this was incorrectly denied based 
on routine vision rules. This is a medical procedure for a medical condition. You want the Plan to review this 
based on their medical policies, not the supplemental benefit. The Plan denied your request. The Plan says the 
services requested are noncovered. 
 
The Plan follows Medicare rules. Medicare rules say that scleral shells may be considered medically reasonable 
and necessary in the circumstances described in the Medicare rules section of this decision.  
 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 scleral shell and fitting. Our 
reviewer says that the documentation does not support that the NCD rules are met for coverage of the requested 
services. Our physician reviewer found the record indicates that the enrollee has keratoconus and dry eye. The 
record indicates that the enrollee uses artificial tears four times daily. The provided record is insufficient to 
establish that the coverage criteria are satisfied. The elements of the coverage criteria 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 scleral shell and fitting have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a gas permeable hard contact lens (scleral shell) with associated fitting.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no documentation to support these services. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. While the patient has 
a history of atrial fibrillation, there is no documentation provided to suggest a history of unexplained syncope, 
cryptogenic stroke or any other apparent indication for an ILR. Our physician reviewer found that the enrollee's 
condition does not meet criteria for coverage of these services. 
 
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 an implantable loop recorder for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for COVID-19 vaccine administration provided on October 28, 2021. 
 
You asked the Plan to pay for COVID-19 vaccine administration. You say that you cannot provide this service 
for free, and the COVID vaccine has been approved by the federal government. The Plan denied your request. 
The Plan says that the denial of payment for this service is correct, because the vaccine is not reimbursable 
although the administration of a vaccine is reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers can bill for administering COVID-19 
vaccines, but not for the COVID-19 vaccines themselves when the vaccines are free. 
 
We looked at the file and Medicare rules. You billed for the administration of a COVID-19 vaccine, which is 
covered and payable by Medicare. Based on this information, we decided that Medicare rules for coverage of 
COVID-19 vaccine administration have been met. Therefore, we decided that the Plan has to pay for COVID-
19 vaccine administration provided on October 28, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided lidocaine injection/hydrodissection to 
the left hip. 
 
You asked the Plan to pre-approve ultrasound guided lidocaine injection/hydrodissection to the left hip. You 
say that this service is needed due to heterotopic ossification on left hip replacement. The Plan denied your 
request. The Plan says the enrollee's records do not show that this procedure is considered reasonable and 
necessary because there is not literature and research to support its use. 
 
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 ultrasound guided lidocaine 
injection/hydrodissection to the left hip. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found that this procedure is considered 
experimental/investigational and therefore, is considered 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 ultrasound guided lidocaine injection/hydrodissection to the left hip have not been met. Therefore, we decided that the Plan does not have to pre-approve ultrasound guided lidocaine 
injection/hydrodissection to the left hip.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve general anesthesia for genicular nerve ablation. 
 
You asked the Plan to pre-approve general anesthesia for genicular nerve ablation. The Plan denied your 
request. The Plan says general anesthesia is not reasonable and necessary for genicular nerve ablation as this 
procedure most routinely only requires local anesthesia. 
 
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 general anesthesia for genicular nerve 
ablation. Our reviewer says that general anesthesia for genicular nerve ablation is not considered medically 
reasonable and necessary. Our physician reviewer found according to the American Society of 
Anesthesiologists (ASA), a monitored anesthesia care (MAC) is a planned procedure during which the patient 
undergoes local anesthesia together with sedation and analgesia. MAC may include varying levels of sedation, 
analgesia, and anxiolysis, including but not limited to moderate sedation.  Moderate sedation/analgesia 
("conscious" sedation) is a drug-induced depression of consciousness during which patients respond 
purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are 
required to maintain a patent airway, and spontaneous ventilation is adequate. In this case, there is no indication for the use of conscious sedation/anesthesia services for the approved 
genicular nerve RFA. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of general anesthesia for genicular nerve ablation have not been met. Therefore, 
we decided that the Plan does not have to pre-approve general anesthesia for genicular nerve ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve radiofrequency ablation procedure 
provided on November 18, 2021. 
 
You asked the Plan to pay for the genicular nerve radiofrequency ablation procedure. You say that the 
genicular nerve radiofrequency ablation procedure provided on November 18, 2021, was medically necessary. 
The Plan denied your request. The Plan says the genicular nerve radiofrequency ablation procedure provided 
on November 18, 2021, was not medically necessary. 
 
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 pay for the genicular nerve radiofrequency ablation procedure. Our reviewer says that the genicular nerve radiofrequency ablation procedure provided on 
November 18, 2021, was not medically necessary. Our physician reviewer found genicular nerve 
radiofrequency ablation is experimental for the treatment of knee pain. More research is needed. 
 
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 genicular nerve radiofrequency ablation procedure have not been met. 
Therefore, we decided that the Plan does not have to pay for the genicular nerve radiofrequency ablation 
procedure provided on November 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 25, 2022, to 
January 26, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says prior authorization was not obtained for these services. 
 
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 inpatient hospital services provided on January 25, 
2022, to January 26, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on January 12, 2022, to January 
26, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that these services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained by a participating 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 physical therapy provided on January 12, 2022, to 
January 26, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99231) provided on February 
10, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee was no longer 
enrolled in hospice on the date of service in this case. The Plan denied your request. The Plan says the 
enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits 
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it 
is the providers responsibility to verify the enrollees coverage before rendering services and to know proper 
billing procedures for a Medicare Advantage member on hospice. 
 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 5, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care (99231) provided on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210, 
81235, 81270, 81272, 81275, 81276, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 
81405, 81406, 81406, 81309) provided on August 16, 2021. 
 
You asked the Plan to pay for Guardant360 testing. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
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 rules also say that code 81479 is used to 
report Guardant360 testing. 
 
We find that CPT codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293, 
81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81406, and 81309 are not supported in the medical record. Specifically, these codes were used to report Guardant360, which should be 
reported with 81479. Based on this information, we decided that Medicare rules for coverage of Guardant360 
testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing 
(81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293, 81310, 81311, 81314, 
81321, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81406, 81309) provided on August 16, 2021.