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

 
We decided that the Plan does not have to waive the copayment for knee injections provided on June 21, 2022, 
to June 28, 2022. 
 
You asked the Plan to waive the copayment for knee injections. You say that you were told you wouldnt have 
to pay these copayments. The Plan denied your request. The Plan says this cost sharing was charged 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 a $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for knee injections. This item/service falls within the 
physician/practitioner services, including doctors office visits 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. You had two visits, each had a $40 copayment 
($40 x 2 visits = $80). Therefore, we decided that the Plan does not have to waive the copayment for knee 
injections provided on June 21, 2022, to June 28, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on May 21, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the transport was 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on May 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the NeoGen Series inferential therapy (transcutaneous 
electric cell signaling). 
 
You asked the Plan to pay for the NeoGen Series inferential therapy. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the request is not a covered benefit as this therapy is 
being used within the physician's office for continued therapy to treat peripheral neuropathy. 
 
The Plan must follow Medicare rules. Medicare rules say that electrical nerve stimulation treatments furnished 
by a physician in his/her office, by a physical therapist or outpatient clinic are excluded from coverage 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the NeoGen Series inferential therapy have not been met. Specifically, the request is not a covered 
benefit as this therapy is being used within the physician's office for continued therapy to treat peripheral 
neuropathy. Therefore, we decided that the Plan does not have to pay for the NeoGen Series inferential therapy 
(transcutaneous electric cell signaling).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided 
from April 4, 2022, through May 3, 2022. 
 You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee did not meet criteria for coverage 
of the inpatient skilled nursing facility (SNF) care provided. 
 
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 pay for the SNF care. Our reviewer says that the 
SNF care provided was not medically reasonable and necessary based on Medicare guidelines. Our physician 
reviewer found that the enrollee did not require skilled nursing or skilled therapy services on a daily basis. 
Additionally, as a practical matter, the enrollee did not meet severity of illness or intensity of service criteria 
for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the inpatient skilled nursing facility (SNF) care provided from April 4, 2022, through May 3, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit and the debridement of nails 
provided on May 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit and the debridement of nails. You say that you 
would like the submitted records reviewed, proving medical necessity. 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 were not 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit and the 
debridement of nails provided on May 31, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on May 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that the services provided to the enrollee were 
medically necessary. The Plan denied your request. The Plan says the rendering and referring providers are 
both OON providers and there was no approved authorization. Also, the service rendered was not urgent or 
emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home health visit provided on May 31, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
October 22, 2021. 
 
You asked the Plan to pay for procedure code 99100 and 99140. You say that this should be paid for. The Plan 
denied your request. The Plan says procedure code 99100 and 99140 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. This means that procedure codes 99100 and 99140 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure code 99100 and 99140 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
October 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the abdomen. 
 
You asked the Plan to pre-approve a CT of the abdomen. You say that you would like the enrollee to be 
approved for the CT scan given their clinical presentation and history. The Plan denied your request. The Plan 
says this request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT of the abdomen. Our reviewer 
says that a CT of the abdomen is not reasonable and necessary for the enrollee. Our physician reviewer found 
there is no evidence of any abdominal symptom or abnormal physical exam/lab abnormality related to the 
abdomen. Our reviewer also found that no malignant diagnosis of the chest is yet seen in the records. 
 
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 CT of the abdomen have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) of the abdomen.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided June 24, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you believe should not be charged. The 
Plan denied your request. The Plan says this cost sharing was charged 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 a $275 
copayment for outpatient diagnostic tests/Medicare covered services.  
 
You have been asked to pay a $275 copayment for CT scan. However, you are only being charged $119.85 
Which is less than the required amount.This item/service falls within the outpatient diagnostic tests/Medicare 
covered 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 a computed 
tomography (CT) scan provided June 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lung scan. 
 
You asked the Plan to pre-approve a lung scan. The Plan denied your request. The Plan says this request does 
not meet criteria for medical necessity as there is insufficient evidence that the requested service meets the 
reasonable and necessary standard for medical necessity. 
 
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 a lung scan. Our reviewer says that the 
requested lung scan is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has ischemic heart disease. Our reviewer found that the enrollee does not have lung or 
pulmonary vascular disease that would require a ventilation-perfusion lung scan. 
 
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 lung scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lung scan.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a duplex scan of extracranial arteries. 
 
You asked the Plan to pre-approve a duplex scan of extracranial arteries. You say that this service is medically 
necessary for the evaluation and treatment of the enrollee's medical condition. The Plan denied your request. 
The Plan says that the enrollee is asymptomatic and does not have any of the conditions or findings to support 
medical necessity and approval of the request. The Plan also says this carotid duplex scan is not reasonable or 
necessary at this time. 
 
The Plan follows Medicare rules. Medicare rules say that dizziness is not a typical indication for non-invasive 
cerebrovascular studies unless associated with other localizing neurologic signs or symptoms. 
 
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 duplex scan of extracranial arteries. 
Our reviewer says that a duplex scan of extracranial arteries is reasonable and necessary for the enrollee. Our 
physician reviewer found the enrollee has diffuse atherosclerotic disease including right leg stent and 
abdominal aortic aneurysm.  As such, it is reasonable to assume multiple vessels are involved and the 
symptoms of dizziness and giddiness are valid indications for duplex scan of the extracranial arteries of the 
neck. Our reviewer found that even without a bruit on physical exam, the evaluation of these arteries is 
indicated looking for hemodynamically significant stenosis given the clinical history. Our physician reviewer 
also found that calculation of intimal thickness is also useful in management and will be assessed with the 
requested study. 
 
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 duplex scan of extracranial arteries have been met. Therefore, we decided that 
the Plan has to pre-approve a duplex scan of extracranial arteries.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab services 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 lab services provided on November 15, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT), head or brain (70450) 
provided on May 7, 2022. 
 
You asked the Plan to pay for the CT scan. You say that this service should be covered. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the computed tomography (CT), head or brain (70450) 
provided on May 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental x-rays (D0220) provided by an out-of-network 
provider on July 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental x-rays (D0220) provided by an out-of-network provider on July 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 21, 2022, through 
April 5, 2022. 
 
You asked the Plan to pay for home health services. You say that you tried several times to submit the NOA 
but were denied every time. You say that the claim should be reconsidered for payment. The Plan denied your 
request. The Plan says a valid NOA is required in order to process the final claim. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services under a plan of care are 
paid based on a 30-day period of care. HHAs submit an NOA at the beginning of an admission and then submit 
one claim for each 30-day period of care. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, an NOA was not submitted. Therefore, we 
decided that the Plan does not have to pay for home health services provided from March 21, 2022, through 
April 5, 2022.
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 feel this denial should be 
reconsidered, and authorization be granted for the enrollee to be admitted to the LTACH. The Plan denied your 
request. The Plan says the enrollee appears to be receiving appropriate care at the current facility. The Plan also 
says that a transfer to the LTACH is not medically necessary as it would not be clinically advantageous. 
 
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 continues to receive acute care services and these have not been denied. 
The medical record does not indicate that the enrollee requires services that they are not currently receiving but 
that would be available at the LTACH facility. Our reviewer also found that the elements of the coverage rules 
are not satisfied, and the requested service cannot be 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the intraoperative neuromonitoring provided on January 11, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the 
services were not medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the Plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The enrollee was referred for the services by a contract provider. The file does not show that the Plan provided 
notice that the services provided would not be covered. Under Medicare rules, this means the services provided 
is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the intraoperative 
neuromonitoring provided on January 11, 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.