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

 
We decided that the Plan does not have to pay for the trigger point injection provided on April 20, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the trigger point injection. You say that the injection was medically necessary 
because the enrollee has myofascial pain syndrome. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
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 
trigger point injection. We found no exception that would require the Plan to pay for the trigger point injection. 
The records provided for review do not show that the trigger point injection was urgent or emergent. Therefore, 
we decided that the Plan does not have to pay for the trigger point injection provided on April 20, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osteoplasty provided to the enrollee on December 3, 2021. 
 
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 providers are required to furnish necessary information to the health plan when requested. 
 
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, the CPT Code Manual definition of code 21209 is "Osteoplasty, facial bones; reduction." 
 
We asked our coder 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 in the medical records. Our reviewer found that the record indicates that the 
enrollee had a maxillary abscess. The record provided does not included a description of the operative 
procedure actually performed. Therefore, the appropriateness of the provided code cannot be determined. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for osteoplasty provided to the enrollee on December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5267) provided on March 4, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you believe it is reasonable for the Plan to provide 
some coverage for these hearing aids. The Plan denied your request. The Plan says hearing aids must be 
purchased through the Plan's approved hearing aid vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor to use your hearing aid benefits.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5267) provided on March 4, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient mental health services provided from November 20, 2021, to 
November 30, 2021. 
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that this was medically 
necessary. The Plan denied your request. The Plan says that there were no acute medical problems or 
medication issues that would have necessitated this admission and stay at the acute level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our 
reviewer says that the services at issue in this case were medically reasonable and necessary. Our physician 
reviewer found that it was expected that this enrollee would improve in a reasonable period of time, as she had 
dangerousness to self (but not others), and was not showing any auditory/visual hallucinations or any 
aggressive behaviors. It did appear medically necessary and reasonable to have psychiatric care provided at the 
acute inpatient level of care rather than a lower level of care. The health plans denial of inpatient psychiatric 
services appears inappropriate. This enrollee did appear to require inpatient mental health treatment, and was 
cooperative with care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pay for inpatient mental health services provided from November 20, 2021, to November 
30, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 15, 2021. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says the tests are included in the 
dialysis services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on February 8, 2022. 
 
You asked the Plan to pay for the testing services. You say that there is no agreement that the codes billed are 
included in the dialysis rate. The Plan denied your request. The Plan says the testing is not separately 
reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the lab testing provided on February 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face down recovery equipment provided on February 7, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the face down recovery equipment. You say that you were told you can use any 
provider for the equipment, and you would only be charged a coinsurance payment. The Plan denied your 
request. The Plan says the rendering provider is an OON provider and there was no approved authorization. 
Also, it was confirmed with an in-network provider that they carry the equipment, and it is available. 
 
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 the face down recovery equipment provided on 
February 7, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 12, 2022. 
 
You asked the Plan to pay for the testing services. You say that there is no agreement that the codes billed are 
included in the dialysis rate. The Plan denied your request. The Plan says the services are the responsibility of 
the dialysis center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on January 12, 2022. 
 
You asked the Plan to pay for the testing services. You say that there is no agreement that the codes billed are 
included in the dialysis rate. The Plan denied your request. The Plan says the tests are bundled into the dialysis 
services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the lab testing provided on January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically reasonable and 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology service provided on March 16, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical pathology service. You say that you are an independent laboratory 
and always bill separately from the hospital. You say the enrollee's ordering physician is responsible for 
obtaining the authorization. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
 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 
surgical pathology service. We found no exception that would require the Plan to pay for the surgical pathology 
service. The records provided for review do not show that the surgical pathology was urgent or emergent. 
Therefore, we decided that the Plan does not have to pay for the surgical pathology service provided on March 
16, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the inpatient hospital care provided from  
December 17, 2021, through December 22, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly 
to the services provided. 
 
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. Specifically, the Plan has not forwarded the correct Evidence of Coverage 
(EOC) contract for the year 2021 in which the services were rendered. We are unable to determine the 
applicable copayment liability in this case. The Plan has not substantiated their denial; therefore, we must find 
in your favor. Therefore, we decided that the Plan has to waive the copayment for the inpatient hospital care 
provided from December 17, 2021, through December 22, 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 waive the coinsurance for a denosumab injection provided on 
February 18, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that these injections were covered 
before. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay $508.92, which is 20% of the allowed amount for the injection ($2,544.60 allowed 
amount x 20% coinsurance = $508.92). The injection falls within the Medicare Part B Prescription Drugs 
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 coinsurance for a denosumab injection provided 
on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital outpatient clinic visit, and wound 
debridement of subcutaneous tissue provided from November 16, 2021, to December 21, 2021. 
 
You asked the Plan to waive the copayment for hospital outpatient clinic visit, and wound debridement of 
subcutaneous tissue. You say that you were told that you could not receive home wound care because you were 
doing outpatient physical therapy. You were also told that home wound care would not be approved. You also say you were not told that this facility was an outpatient clinic and required a $100 copayment per visit. The 
Plan denied your request. The Plan says you were 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 $100 
copayment for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical 
center, including but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay a $100 copayment for each hospital outpatient clinic visit, and wound debridement 
of subcutaneous tissue for five visits, which is a total of $500 ($100 x 5 = $500). Hospital outpatient clinic 
visits, and wound debridement of subcutaneous tissue fall within the outpatient surgery and other medical 
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 hospital outpatient clinic visit, and wound debridement of 
subcutaneous tissue provided from November 16, 2021, to December 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
September 18, 2021, to October 13, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim was not submitted with the 
required RAP claim form. 
 
The Plan must follow Medicare rules. The rules say that a RAP must be submitted in order for payment to be 
made. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim 
form that was submitted was billed with Type of Bill 329 which indicates this is not the RAP which has a Type of Bill of 322. It is unclear at this time if the RAP was submitted.  Therefore, we decided that the Plan does not 
have to pay for the home health services provided to the enrollee from September 18, 2021, to October 13, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on April 4, 2022, to April 12, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physical therapy. You say that it was convenient for you to attend the 
physical therapy in your senior home because you have a walker and must carry oxygen tank. The Plan denied 
your request. The Plan says no prior authorization was obtained. 
 
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 physical therapy. The Plan did not pre-approve the physical therapy. We 
found no exception that would require the Plan to pay for the physical therapy. Therefore, we decided that the 
Plan does not have to pay for physical therapy provided on April 4, 2022, to April 12, 2022, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (81003, 84436, G0378) billed for date of 
service June 7, 2021 to June 10, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed.  
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 84436 
is a column II code to column I code 84439. This claim has not been billed with an appropriate modifier to 
bypass the edit. Code 81003 was billed without a required modifier, and code G0378 was billed twice for the 
same date of service. Observation codes can only be billed once per date of service for this place of service. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for outpatient services (81003, 84436, G0378) billed for date of service June 7, 2021 to 
June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by 
the out-of-network (OON) provider on April 3, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out-of-network 
provider, without prior authorization. 
 
 
 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 had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the chiropractic manipulative treatment (98941) rendered by the out-of-network 
(OON) provider on April 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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. 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 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing 
facility setting. Records do not document those services in the home with home health care or in a long-term 
care facility on a part time basis are not appropriate in this case. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.