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

 
We decided that the Plan does not have to pay for the emergency room (ED) evaluation and management (EM) 
services provided on November 6, 2020, billed with code 99284-25. 
 
You asked the Plan to pay for the ED EM services. You say that this was billed correctly as the enrollee had a 
separate and identifiable EM service as well as the elbow dislocation procedure. The Plan denied your request. 
The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that EM services during which the need for a major 
surgery is identified are payable when billed with modifier -57. Modifier -25 should not be used.   
 
We looked at the file and Medicare rules. The EM services were provided on the same date as code 24600. This is a major surgery code. The use of modifier -25 is not allowed with the EM service when billed with a 
major surgery. Based on this information, we decided that Medicare rules for coverage of the ED EM services 
have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ED) 
evaluation and management (EM) services provided on November 6, 2020, billed with code 99284-25.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Determination of refractive state (92015) provided February 
10, 2022. 
 You asked the Plan to pay for the vision services. You say that you were not informed that the provider became 
out of network as of January 2022 and that you would be responsible for this service. The Plan denied your 
request. The Plan says Refraction is only covered when billed as part of the routine eye exam. 
 
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. The Plan covers these services when billed as part of the routine eye exam. 
 
We looked at the file and the Plan's rules. The records show that the refraction services was completed as part 
of a medical exam and not a routine exam. Based on this information, we decided that the Plan's rules for 
coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for 
Determination of refractive state (92015) provided February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy and office visit provided on February 8, 
2022 by an OON provider. 
 
You asked the Plan to pay for a psychotherapy and office visit. You say that you are appealing the denial of 
payment for services provided. The Plan denied your request. The Plan says out-of-network services were not 
authorized. 
 
 
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 psychotherapy and office visit provided on 
February 8, 2022 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spinal manipulation services and other billed codes 
provided by an out-of-network (OON) chiropractor from January 19, 2022, through January 26, 2022. 
 
You asked the Plan to pay for the chiropractor-rendered OON services. You say that the enrollee is entitled to 
coverage of all Medicare-covered services. The Plan denied your request. The Plan says most of the denied 
services are not covered by Medicare when provided by a chiropractor. As for code 98940, this is Medicare-
covered but was provided OON without authorization. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The rules also allow Plans to restrict enrollees to 
network providers.  
 The records show that the services at issue are not manual manipulation of the spine. As for the spinal 
manipulation, this was provided OON without authorization. There were network providers able to render this 
care. Therefore, we decided that the Plan does not have to pay for the spinal manipulation services and other 
billed codes provided by an out-of-network (OON) chiropractor from January 19, 2022, through January 26, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatment. 
 
You asked the Plan to pre-approve acupuncture treatment. You say that acupuncture treatment is medically 
necessary. The Plan denied your request. The Plan says acupuncture treatment is not medically necessary. 
 
The Plan follows 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 if there is demonstrated improvement. 
 
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 acupuncture treatment. Our reviewer 
says that the requested acupuncture treatment does not meet the Medicare coverage criteria. Our physician 
reviewer found based on the Medicare requirements for acupuncture, an approved indication is needed, and the 
only one is low back pain which was not listed in the documentation provided.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acupuncture treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve acupuncture treatment.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy and office visit provided on January 26, 
2022, by an OON provider. 
 
You asked the Plan to pay for a psychotherapy and office visit. You say that you are appealing the denial of 
payment for services provided. The Plan denied your request. The Plan says the provider is a non-network 
provider. The enrollee's primary care provider did not refer the 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 a psychotherapy and office visit provided on 
January 26, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies rendered on December 
16, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that there is no detailed written order. 
 
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 there is no detailed written order; however, the 
documentation contains a valid detailed written order. Therefore, we decided that the Plan has to pay for the 
continuous glucose monitor (CGM) supplies rendered on December 16, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on January 27, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that authorization should be on file and 
should fall under the authorization as they rendered services in good faith. The Plan denied your request. The 
Plan says the services were provided out-of-network and were not approved in advanced. 
 
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 
domiciliary or rest home visit at issue. We found no exception that would require the Plan to pay for 
domiciliary or rest home visit. Therefore, we decided that the Plan does not have to pay for domiciliary or rest 
home visit provided on January 27, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the radiology services provided on January 6, 2022. 
 
You asked the Plan to pay for the radiology services. You say that you provide interpretation of the radiology 
procedures that the referring provider request. The Plan denied your request. The Plan says that the rendering 
provider is an OON provider and there was no approved authorization. 
 
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 claim information submitted lists a referring physician. The Plan did not 
submit documentation supporting that the referring physician is also out-of-network. It is the burden of the 
Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we 
must find in your favor. Therefore, we decided that the Plan has to pay for the radiology services provided on 
January 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit for the evaluation and 
management of an established patient provided on February 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit for the evaluation and management of an 
established patient. You say that an authorization should be on file for their stay. The Plan denied your request. 
The Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to the 
services being rendered. 
 
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 domiciliary or rest home visit for the evaluation 
and management of an established patient provided on February 1, 2022, by an out-of-network (OON) 
provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF services after June 29, 2022. 
 
You asked the Plan to pre-approve continued SNF services after June 29, 2022. You say that you need 
continues SNF services. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
continued SNF care after June 29, 2022. 
 
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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the medical records do not document that 
you require services on an inpatient basis, only in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve extended SNF stay.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. The Plan denied your request. The Plan says 
the enrollee does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found that in 
this case, the epidural steroid injection on March 16, 2022 only provided 50% pain relief for a period of one (1) 
month. The review has determined that the requested epidural steroid injection does not meet the Medicare 
LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous neuromodulation therapy (PNT) (64555, 
64575, 64590). 
 
You asked the Plan to pre-approve PNT. You say that the enrollee has failed and exhausted all recommended 
conservative treatment to this point yet still has knee pain and this would be the only option at this point. The 
Plan denied your request. The Plan says the requested therapy does not meet criteria. 
 
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 PNT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee underwent RFA of the right genicular nerves but did not achieve pain relief. The 
request is for placement of Stim Wave peripheral nerve stimulator. This is considered experimental/ 
investigational as there is no long-term data on outcomes and complications. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PNT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous neuromodulation therapy (PNT) (64555, 64575, 64590).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Micro-Invasive Glaucoma Surgery (66691). 
 
You asked the Plan to pre-approve the glaucoma surgery. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that this procedure is covered for treatment of adults with 
mild or moderate open-angle glaucoma and a cataract when the individual is currently being treated with an 
ocular hypotensive medication and the procedure is being performed in conjunction with cataract surgery. 
 
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 glaucoma surgery. Our reviewer 
says that this procedure is not medically necessary. Our physician reviewer found the record shows that the 
enrollee is not on any medications for glaucoma. Coverage criteria has not been met. 
 
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 glaucoma surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Micro-Invasive Glaucoma Surgery (66691).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a bladder neck resection procedure 
performed on August 18, 2021. 
 
You asked the Plan to waive the copayment for the resection. You say that you cannot afford the copayment. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 each outpatient hospital visit.  
 
You have been asked to pay a $300 copayment for the resection. The resection falls within the Outpatient 
Surgery, Including Service Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 bladder neck resection procedure performed 
on August 18, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
January 31, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were informed that all COVID-
19 related treatments. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 $90 
copayment for each emergency care visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit 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 an emergency room (ER) visit 
provided on January 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
November 22, 2019, to November 26, 2019. 
 
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 a DRG assignment change was appropriate.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 374 (DIGESTIVE MALIGNANCY WITH 
MCC). 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found DRG 
376: DIGESTIVE MALIGNANCY WITHOUT CC/MCC was the more appropriate DRG according to the 
medical records.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from November 22, 2019, to November 26, 2019.