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

 
We decided that the Plan does not have to pay for radiology services provided on July 13, 2020. 
 
You asked the Plan to pay for the radiology services. You say that the claim was filed within the timely filing 
guidelines. The Plan denied your request. The Plan says the claim was not received within 12 months from the 
date of service. 
 
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 service. 
 
The record shows that a claim for the radiology services was not filed until April 25, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. You have not 
provided any evidence showing that a claim was filed within 12-months of the date of service in dispute. 
Therefore, we decided that the Plan does not have to pay for radiology services provided on July 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair items. 
 
You asked the Plan to pre-approve the requested items. You say that the wheels get stuck in the grass and 
cracks. The Plan denied your request. The Plan says the request does not meet coverage criteria. 
 The Plan must follow Medicare rules. Medicare rules say that wheelchair options and accessories are only 
covered under certain medical indications. 
 
We looked at the file and Medicare rules. The approved wheelchair includes wheels and wheel locks. The 
requested items are for use outside the home. The requested impact guards are a convenience item and not used 
for a primary medical purpose. Based on this information, we decided that Medicare rules for coverage of the 
requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve 
wheelchair items.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance transports and ER visits 
provided from May 13, 2022, through May 15, 2022. 
 
  You asked the Plan to waive the copayments for the ambulance transports and ER visits. You say that you do 
not pay for an ambulance after a hospital stay due to a misdiagnosis. The Plan denied your request. The Plan 
says the copayment for the CT scan will be paid in full and the remaining copayments applied 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 $275 for 
each one-way Medicare-covered ambulance transport and $90 for each Medicare-covered emergency room 
visit.  
 
You have been asked to pay a total of $730 for the ambulance transports and ER visits.  
 
Date of Service Service Copayment Per Contract Member Liability 
May 13, 2022 Ambulance Transport $275 $275 
May 13, 2022, to May 14, 2022 ER Visit $90 $90 
May 15, 2022 Ambulance Transport $275 $275 
May 15, 2022 ER Visit $90 $90 
TOTAL:   $730 
 
The ambulance transports fall within the Ambulance Services benefit category. The ER visits fall 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 copayments for the ambulance 
transports and ER visits provided from May 13, 2022, through May 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CX Bladder test represented by code 0012M and billed for 
date of service February 14, 2022. 
 
You asked the Plan to pay for the CX Bladder test. You say that the services in dispute were medically 
necessary. The Plan denied your request. The Plan says the CX Bladder test remains unproven at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that the CX Bladder test is non-covered. Therefore, 
we decided that the Plan does not have to pay for a CX Bladder test represented by code 0012M and billed for 
date of service February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a tumor treatment field therapy device (TTFT). 
 
You asked the Plan to pre-approve TTFT device. You say that any time you do not have this device you are at 
risk for cancer returning. The Plan denied your request. The Plan says TTFT is not reasonable and necessary 
for the treatment of recurrent glioblastoma. 
 
The Plan follows Medicare rules. Medicare rules state that TTFT is only covered if certain criteria are met and 
will be denied as not reasonable and necessary for the treatment of recurrent Glioblastoma Multiforme (GBM). 
 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 TTFT device. Our reviewer says that 
you do not meet the Medicare criteria for use of the TTFT device. Our physician reviewer found as there are 
really no other viable options for you other than what has already been administered, any potentially effective 
treatment should be considered, so it would be reasonable to consider tumor treatment fields. However, tumor 
treatment fields are not covered for recurrent glioblastoma. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTFT device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of a tumor treatment field therapy device (TTFT).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a single photon emission computed 
tomography (SPECT) scan and the coinsurance for Part B medication administration provided on April 18, 
2022. 
 
You asked the Plan to waive the copayment for a SPECT scan and Part B medication administration. You say 
that you were not advised by anyone that there would be a copay, or that you would be responsible for 
coinsurance since the injection was part of the test. The Plan denied your request. The Plan says the copayment 
applied was 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 $75 
copayment for Medicare-covered Nuclear Medicine at a freestanding provider or at an outpatient hospital 
setting and 20% coinsurance for Part B medications and contrast agents injected during the service or Part B 
medications topically applied during the service.  You have been asked to pay a total of $79.23 ($75 copayment for a SPECT scan and $4.23  which is 20% of 
the allowed amount of $21.16 for Part B medication administration. $75 + $4.23 = $79.23) A SPECT scan and 
Part B medication administration fall within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies 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 single photon emission 
computed tomography (SPECT) scan and the coinsurance for Part B medication administration provided on 
April 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan provided on November 18, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the duplex scan. You say that this service was medically necessary and 
performed in the proper setting. 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 this scan nor the referring provider is a network provider with the Plan. 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 duplex scan provided on 
November 18, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says 
that these services are not urgent or emergent, nor were they 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 an office visit provided on May 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care (99304) provided on February 
18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the medically necessary services were 
provided at the request of the skilled nursing facility (SNF) or primary care physician (PCP). The Plan denied 
your request. The Plan says the services were not performed at the request of an in-network provider. The Plan 
also says that the service was not urgent or emergent in nature. 
 
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 in this case is not a network provider with the Plan. The record does not show that the services 
were provided at the request of the enrollees PCP, or other network provider. 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 initial nursing facility care (99304) provided 
on February 18, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on March 21, 2022, and 
March 22, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that it was impossible for the medications 
to be self-administered while you were in the hospital. The Plan denied your request. The Plan says charges for 
self-administered drugs should be submitted to your Part D prescription plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on March 21, 2022, and March 22, 2022.  
 Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home healthcare services provided from September 14, 
2021, to September 21, 2021. 
 
You asked the Plan to pay for the home healthcare services. You say that you would like this claim to be 
reconsidered for payment. The Plan denied your request. The Plan says the non-contracted provider did not 
submit the RAP claim for services for dates of service September 14, 2021, to September 21, 2021, until 
February 24, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home healthcare services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the home healthcare services provided from September 14, 2021, to September 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services can provide the 
medical needs to get your strength back. The Plan denied your request. The Plan says the clinical assessment 
does not support the expectation of a stay to be at least 25 days in an LTACH. The enrollee's medical needs are 
being met in the current acute setting. The LTACH would add no additional services. With additional time in 
the current setting, clinical stability can be ensured such that the appropriate lower level of care can be 
determined. 
 
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 enrollee appears to be stable and improving and should only require short-
term additional acute care hospital services that can be safely administered at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it 
would not be clinically advantageous. Completion of treatment at the current facility is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that this specific bed is necessary for 
your condition. The Plan denied your request. The Plan says a total electric hospital bed is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lamotrigine ER. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lamotrigine ER.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic nasal endoscopy provided on 
April 19, 2022. 
 
You asked the Plan to waive the copayment for a nasal endoscopy. You say you did not know that your 
insurance wouldn't cover this service. The Plan denied your request. The Plan says the copayment applied was 
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 $275 
copayment for each Medicare-covered outpatient hospital facility visit. 
 
You have been asked to pay a total of $163.47 which is less than the standard $275 copayment for a nasal 
endoscopy. A nasal endoscopy falls within the Outpatient Surgery, Including Services 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 diagnostic nasal endoscopy provided on April 19, 2022.
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 that the enrollee would lack the ability to regain 
maximum function at a lower level of care. The Plan denied your request. The Plan says rules for IRF care 
have not been met. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 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 pay for the nursing home visit provided on March 10, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing home visit. You say that the provider depended on the facility's staff 
to verify eligibility and obtain the proper authorization. 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. 
 The provider in this case is not a network provider with the Plan. 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 nursing home visit provided on March 10, 2022, by an out-
of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 5, 2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 
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, we have confirmed that code 76705 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee injection. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee did not have improvement in pain. The Plan must follow Medicare rules. Medicare rules say that injections for knee osteoarthritis are only covered 
under certain medical indications.  
 
We looked at the file and Medicare rules. The records do not show that the re was improvement in knee pain 
from the previous injection Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a knee injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service March 10, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 71045 is bundled into payment for code 32557. 
 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, we have confirmed that code 71045 
is a column II code to column I code 32557. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 71045 billed for date of service March 10, 2022.