Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 11, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that prior dates of service were paid, and you would like 
this claim to be paid. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
provider and there was only an approved authorization for 2 prior dates of service. There was no approved 
authorization for the date of service on this claim or for continuation of care. 
 
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 August 11, 2021, by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
September 26, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you needed the 
transportation to a skilled nursing facility and would like the copayment removed. The Plan denied your 
request. The Plan says the proper copayment was applied. 
 
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 $240 
copayment for each Medicare-covered ground transportation service.  
 
  You have been asked to pay a $240 copayment for ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 
the ambulance transportation provided on September 26, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the records provided support the need for SNF care. 
The Plan denied your request. The Plan says that the enrollee does not meet the guidelines for services in a 
SNF setting. 
 
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 
criteria for coverage have been met. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs.  The enrollee does have documented skilled therapy needs.  The enrollee is functioning 
below her baseline.  Daily skilled services are required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 pay for venipuncture (36410) and ultrasound guidance for vascular 
access (76937) provided on August 8, 2021. 
 
You asked the Plan to pay for venipuncture and ultrasound guidance. You say that these services were 
necessary and were billed correctly The Plan denied your request. The Plan says a National Correct Coding 
Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 36410 and 01230. This PTP edit has a 
modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. This service was not billed as required by Medicare coding 
regulations. 36410 is not separately payable with 01230. In addition, 76937 is an add-on code, and this service 
was not billed with an appropriate primary procedure. 
 
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 36410 
is a column II code to column I code 01230. This claim has not been billed with an appropriate modifier to 
bypass the edit. In addition, 76937 is considered an add-on code, and this service was not billed with an 
appropriate, valid primary procedure. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for venipuncture (36410) and ultrasound 
guidance for vascular access (76937) provided on August 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. 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 October 20, 2021. 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 laboratory 
services provided on October 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) from skull base to mid-thigh. 
 
You asked the Plan to pre-approve a PET/CT scan from skull base to mid-thigh. 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. Medicare rules say that PET 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 a PET/CT scan from skull base to mid-
thigh. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
enrollee does not have a biopsy proven malignancy and the ultrasound showed benign features of the 
intramammary lymph node.  No size was given for the node. If clinical concern for a malignant lymph node 
exists an ultrasound guided biopsy would be appropriate. Evaluation with PET is not clinically indicated for 
such a node without a confirmed pathologic malignancy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET/CT scan from skull base to mid-thigh have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) from skull base to mid-thigh.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from September 27, 2020, through 
October 26, 2020. 
 
You asked the Plan to pay for the home health services. You say that the claim should be reprocessed for 
underpayment adjustment of $618.46 owed on this claim. The Plan denied your request. The Plan says that the 
documentation submitted did not include a recertification OASIS to support the episode of September 27, 2020 
 November 25, 2020. 
 
The Plan must follow Medicare rules. Medicare rules say that certain data elements must be completed for 
home health care services to be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the provider submitted the OASIS for the 
period at issue, which was completed within the required timeframe. Therefore, we decided that the Plan has to 
pay for the home health services provided from September 27, 2020, through October 26, 2020.  
 
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 pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that IMRT is medically necessary. The Plan denied your 
request. The Plan says IMRT treatment is not medically necessary and does not meet the Medicare coverage 
article, A58236. 
 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 IMRT. Our reviewer says that IMRT is 
not medically necessary. Our physician reviewer found that the consult note describes multiple courses of 
antibiotics and surgeries for what is a chronic condition. Radiotherapy appears to be reasonable option for the 
enrollee given the resistance to other treatments. The enrollee is prescribed a dose and fractionation, which is in 
line with published data. In terms of the need of IMRT vs. standard 2D or 3D radiation, this is a bit more 
challenging. The appeal records document the need for radiation but do not specifically address the need for 
IMRT over 2D or 3D conformal radiation. The records show what appears to be large field, albeit with a very 
low dose commonly used for palliation (8 Gy) divided into 8 treatments. With such a low dose it is unclear why 
IMRT is specifically needed over 2D or 3D conformal radiation as risks of toxicity from treatment are expected 
to be very low with the doses prescribed such that it is unclear what normal tissue risks would be mitigated 
with IMRT. As IMRT is not specifically supported, my decision is in favor of radiotherapy but not in favor of 
IMRT planning or delivery given the absence of a plausible rationale for specifically why IMRT would be 
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 IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve IMRT.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and psychotherapy services provided on 
November 9, 2021. 
 
You asked the Plan to pay for an office visit and psychotherapy services. The Plan denied your request. The 
Plan says there is no referring provider involved in these services. Our Plan did not authorize any services for 
this 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit and psychotherapy services provided on 
November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Hospital Services provided on June 29, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient Hospital Services. You say that you would like to appeal the denial of 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct. 
 
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 Outpatient Hospital Services provided on June 29, 
2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services (G0299) provided from July 1, 
2021, to July 26, 2021. 
 
You asked the Plan to pay for skilled nursing care. You say that these services were medically necessary and 
were referred by a participating provider. The Plan denied your request. The Plan says they agree that these 
services were referred by a Plan provider; however, this claim is missing the necessary additional line item 
which reports the location where services were provided using one of the three Q codes (Q5001, Q5002, 
Q5009). Payment will be considered after a corrected claim is provided directly to the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
location where a Home Health Agency (HHA) provides skilled nursing and skilled therapy visits must be 
reported with an additional line item with the same revenue code and date of service, reporting one of three Q 
codes (Q5001, Q5002, Q5009). 
 
We find that the skilled nursing care is not supported in the record. Specifically, these services were billed 
without one of the necessary location-based Q codes. A corrected claim may be submitted directly to the Plan. 
Based on this information, we decided that Medicare rules for coverage of skilled nursing care have not been 
met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services (G0299) provided 
from July 1, 2021, to July 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy (90834) provided on December 2, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that the in-network provider failed to keep her 
appointments by phone, and since you were previously referred to this provider, you thought you would go 
back there. The Plan denied your request. The Plan says despite the prior authorization denial, the member still 
received services from this out-of-network provider on December 2, 2021. The Plan also says that authorization 
from the Plan should be obtained prior to seeking care. 
 
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 psychotherapy (90834) provided on December 2, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Genetic Testing provided on November 24, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Genetic Testing. You say that the member is in a skilled nursing facility and 
doesnt have to option of who takes his labs. The Plan denied your request. The Plan says we have determined 
that these services are not urgent or emergent, nor were they approved in advance. Therefore, we have upheld 
our original determination. 
 
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 Genetic Testing provided on November 24, 2021 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on July 19, 2021. 
 
You asked the Plan to pay for the cardiovascular genetic testing. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says this claim was not billed with the 
appropriate POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the cardiovascular genetic testing have not been met. Specifically, this claim was billed with the 
laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, 
we decided that the Plan does not have to pay for the cardiovascular genetic testing provided on July 19, 2021.
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 the enrollee is too medically complex for 
a skilled nursing facility. The Plan denied your request. The Plan says the enrollee is currently unstable for 
transfer. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with acute on chronic congestive heart 
failure complicated by dysphagia. She was diagnosed with a urinary tract infection, possible sepsis. She was 
treated with dobutamine and antibiotics. Recent notes describe the enrollee as improving but still requiring high 
flow oxygen and is receiving tube feeds. The enrollee should only require short-term additional acute care 
services that can safely be completed at the current facility. Transfer to LTACH is not medically necessary as it 
would not be clinically advantageous. 
 
 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray 
(D0220), and bitewing x-rays (D0274) provided on August 25, 2021. 
 
You asked the Plan to pay for the dental services. You say that you should be reimbursed an additional amount. 
You also say that the services you received previously were unnecessary and unproductive. The Plan denied 
your request. The Plan says the maximum allowance of $2,000 has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the maximum allowance has been 
exhausted.  
   
Date of Service Plan Paid 
1/27/2021 $933 
9/2/2021 $416 
5/22/2021 $485 
8/25/2021 $166 
TOTAL: $2,000 
 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-
ray (D0220), and bitewing x-rays (D0274) provided on August 25, 2021.  
 
Your complaint about services that were paid being unnecessary and unproductive is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints