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

 
We decided that the Plan does not have to pay for psychotherapy services provided from December 6, 2021, to 
March 18, 2022. 
 
You asked the Plan to pay for psychotherapy services. You say that you called several providers and this 
provider is the only one who called you back. The Plan denied your request. The Plan says payment cannot be 
made to providers that opt out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
psychotherapy services provided from December 6, 2021, to March 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerve. 
 
You asked the Plan to pre-approve RFA services. You say that this procedure is medically necessary for your 
condition. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 RFA services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that you are an 88-year-old male with chronic left knee pain due to severe osteoarthritis. 
According to the records submitted, you are not a candidate for knee replacement and has failed injection with 
Synvisc. Your provider has recommended a genicular nerve radiofrequency ablation (RFA). 
 
Genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not 
medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following:  
degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement 
surgery. The review has determined that the genicular nerve ablations are considered 
experimental/investigational in nature and not eligible for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) of the genicular nerve.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on October 11, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the rendering provider is a non-participating provider. The Plan also says 
that there is no referring provider involved in these services, and they 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 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 drug testing provided on October 11, 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 laboratory services rendered on March 3, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 81479 is not supported. 
 
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 81479 is unlisted molecular pathology procedure. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the records show that the 
specimen was not collected on the billed date of service. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered on March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 4, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed without the appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. As the claim was billed with place of service 22, the billed codes 
require modifier -26 for payment to be considered. Based on this information, we decided that Medicare rules 
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on November 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have shown good progress at the hospital and if 
you are transferred to a lower level of care you won't get the level of treatment that you need. You are very 
unbalanced and unable to dress yourself, walk short distances, or go up stairs in your home. You are unable to 
stand without falling. The Plan denied your request. The Plan says IRF care is not medically necessary and you 
can be managed at a lower level of care. 
 
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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that your 
functional status requires this therapy on an intensive IRF level. The September 21, 2022, progress note 
indicates that you have improved gait and are independent in walker use.  
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical records. 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 March 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
26, 2021. 
 You asked the Plan to pay for procedure code 70450. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 26, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 63047 and 69990 billed for date of service 
June 16, 2021. 
 
You asked the Plan to pay for procedure codes 63047 and 69990. You say that the medical records and Waiver 
of Liability were submitted. You say that the claim should be processed in a timely matter. The Plan denied 
your request. The Plan says procedure 69990 cannot be billed with a modifier to bypass the edit. The Plan also 
says procedure code 63047 is not supported because a registered nurse is not eligible for separate 
reimbursement. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS.  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for procedure codes 63047 and 69990 
billed for date of service June 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1391). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need this for use when 
you travel to doctor appointments and other activities. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator (E1391).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on December 3, 2021. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. 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 drug 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 drug testing provided on December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on October 26, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that the enrollee lives in a rural area and has been 
seeing the providers at this office for 40 years. The Plan denied your request. The Plan says the dental services 
were received from an out-of-network provider and are not covered by the enrollees 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 the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on 
October 26, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the odentoplasty (code D9971) you received on June 10, 
2020. 
 
You asked the Plan to pay for the odentoplasty. You say that this procedure should be covered because it was 
the best, most efficient and cost-effective way to solve your problem. The Plan denied your request. The Plan 
says this service is not covered under your dental 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. Though the Plan offers a 
dental benefit, the odentoplasty is not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for the odentoplasty (code D9971) you received on June 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF care is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not have complex rehabilitation, medical, and 
nursing needs. The enrollee dos does not need 3 hours of therapy per day and specialized training, staff, or 
equipment available only in an IRF. The enrollee does not need to be assessed medically and functionally face-
to-face by a rehabilitation doctor, at least 3 days per week. The enrollee does not have a medical complexity 
that needs many doctor visits in an inpatient rehab. The enrollee's rehabilitation needs do not require an 
intensive team approach. The enrollee's needs can be met at an alternate level of care such as a skilled nursing 
facility. 
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the enrollee requires this therapy on an intensive IRF level. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on March 14, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the unique test identifier requirement is missing. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan references Local Coverage Determination (LCD) L35025 and Local 
Coverage Article (LCA) A56853 in their determination; however, these rules are not binding for the state of 
Massachusetts where the testing was performed. The Plan has not provided any Medicare rules or 
documentation to support the services are not payable as billed. Therefore, we decided that the Plan has to pay 
for the laboratory services rendered on March 14, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing evaluation (96132). 
 
You asked the Plan to pre-approve neuropsychological testing evaluation. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the service at issue is not medically 
necessary. 
 
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 neuropsychological testing evaluation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that you do not meet the criteria as you are not showing severity of 
symptoms that would warrant this type of diagnostic treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing evaluation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve neuropsychological testing evaluation (96132).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment applied to emergency room services provided 
on January 25, 2022. 
 
You asked the Plan to waive the copayment applied to the emergency room services. The Plan denied your 
request. The Plan says the cost-sharing amount was appropriately applied to the services in dispute. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for worldwide emergency room visits.  
 
The total allowed amount for the emergency room visit provided on January 25, 2022, was $18.83. You have 
been asked to pay an $18.83 copayment for the emergency room services. The emergency room services fall 
within the worldwide emergency room visits benefit category. The total amount allowed for the emergency 
room visit in dispute is less than the applicable $90 copayment. You were asked to pay the lesser amount. 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 applied to emergency room services provided on January 25, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telemedicine visit on June 1, 
2022. 
 
You asked the Plan to waive the copayment for a specialist telemedicine visit. You say that you feel it is unfair 
to charge the same copayment for a telemedicine visit as for an office visit. The Plan denied your request. The 
Plan says the copayment was 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 a $40 
copayment for a specialist telemedicine visit.  
 
 
 
 
 
 
 You have been asked to pay a $40 copayment for a specialist telemedicine visit. A specialist telemedicine visit 
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. Therefore, we decided that the Plan 
does not have to waive the copayment for a specialist telemedicine visit on June 1, 2022.