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

 
We decided that the Plan does not have to pre-approve three additional acupuncture treatments. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case. 
 In this case, the documentation provided does not indicate that the requested services would be provided by a 
licensed acupuncturist who is under the supervision of a physician. As such, we have concluded that this 
request is not Medicare-covered and the supplemental benefit would apply in this case. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically necessary in this case. Our physician reviewer found that 
the guideline states that your treatment plan may be supported when all of the following criteria are met:  
1) Your complaints, exam findings, and diagnoses correlate with each other; 2) It is supported by the nature 
and severity of your complaints; 3) It is supported by your exam findings; 4) Expected to improve your 
symptoms within a reasonable period of time; and 5) Requires the skills of your provider. The reviewed records 
do not fully support the appeal request and did not meet the Plans internal criteria for the supplemental 
acupuncture benefit offered. 
 
We looked at this physician's review, the file, and the Plans rules. Based on this information, we decided that 
the Plans rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve three additional acupuncture treatments.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy with biopsy performed on 
September 13, 2021. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you thought it was a routine 
colonoscopy and would not be charged. The Plan denied your request. The Plan says you have been 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 $475 
copayment for each outpatient hospital facility visit.  
 
 
 
 
 
 The file shows that the billing code included polyp removal during the procedure. This tissue removal makes 
the procedure a diagnostic surgical procedure. Therefore, you have been asked to pay a $475 copayment for the 
colonoscopy. The colonoscopy falls within the Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for a colonoscopy with biopsy performed on September 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ultrasound of the abdomen's back wall 
provided on March 21, 2022. 
 
You asked the Plan to reduce the copayment for an ultrasound of the abdomen's back wall. You say that you 
have only paid $10 in the past, and never had to pay anything more than $10. 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 per day for a Medicare-covered ultrasound. 
 
You have been asked to pay a total of $62.44, which is less than the $100 copayment for an ultrasound of the 
abdomen's back wall. An ultrasound of the abdomen's back wall falls within the outpatient diagnostic tests and 
therapeutic services and supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for 
an ultrasound of the abdomen's back wall provided on March 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and pay for the in-network emergency services 
and self-administered drugs provided on February 14, 2022. 
 
You asked the Plan to waive the copayment and pay for the emergency services and self-administered drugs. 
You say that you are appealing these charges because you cannot afford to pay it. The Plan denied your 
request. The Plan says you are responsible for a $120 copayment for in-network emergency services that are 
provided at the emergency room. The Plan also says that self-administered drugs are not covered. 
 
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 $120 
copayment for in-network emergency room services. The rules also say that Medicare Part B generally does not 
pay for self-administered drugs. 
 
You have been asked to pay a $120 copayment for the in-network emergency services. The in-network 
emergency services fall within the Emergency care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. The self-administered drugs requested here are also not among the 
types which are covered by Medicare Part B. Based on this information, we decided that Medicare rules for 
coverage of the emergency services and self-administered drugs have not been met. Therefore, we decided that 
the Plan does not have to waive the copayment and pay for the in-network emergency services and self-
administered drugs provided on February 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
January 28, 2022, to January 30, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that the enrollee would not 
have been so bad if someone had taken care of him better to start with. You also say that the enrollee should 
have been admitted on January 23, 2022. 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 $300 
copayment per day for days 1 to 5 for inpatient hospital care.  
 
You have been asked to pay $600 in copayment for two days for inpatient hospital services ($300 copayment x 
2 days = $600). Inpatient hospital services fall within the inpatient hospital care benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services 
provided from January 28, 2022, to January 30, 2022.  
 
Your complaint about the potentially poor service the enrollee received 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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services rendered on August 25, 2021. 
 
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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file shows that the services were previously paid on a separate 
claim. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to 
support that the billed items/services were provided twice on the same date.  Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the physical therapy services rendered on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zoster vaccine rendered on January 5, 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 the services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
Records do not show that the enrollee had not been injured or directly exposed to any illness related to these 
services. Therefore, we decided that the Plan does not have to pay for the Zoster vaccine rendered on January 
5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on February 20, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing services provided on February 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services were 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 an office visit provided on February 15, 2022, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided from December 20, 
2021, to December 22, 2021. 
 
You asked the Plan to pay for critical care. You say that these services were billed appropriately. The Plan 
denied your request. The Plan says these services are not supported 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, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported as billed for these dates. Specifically, the medical records do not 
note the time spent providing these services. Without this information, we cannot verify that 30-74 minutes of 
critical care were provided on each date in question. Based on this information, we decided that Medicare rules 
for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for 
critical care, first hour (99291) provided from December 20, 2021, to December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel rendered on January 5, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
rendered on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Multiplex PCR respiratory viral panels of 6 or more 
pathogens are non-covered. 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that 6 or more pathogens were tested. 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 February 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile gauze rendered on November 15, 2021. 
 
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 the services are not covered. 
 
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 CPT code A6402 has a status indicator of P on the Physician Fee Schedule. This means that CPT 
code A6402 is not payable. 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 sterile gauze 
rendered on November 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on January 17, 2022 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an x-ray. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received in-network. 
 
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 x-ray provided on January 17, 2022 by an out-
of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 IRF admission is not medically necessary based lack of medical complexity and 
acute rehabilitation nursing needs and high functional level. The document does not support the medical 
necessity for admission to an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on February 1, 
2022, to February 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that it is the legal responsibility of the 
insurer to pay medical claims for medically necessary procedures, whether there is an authorization in place or 
not. The Plan denied your request. The Plan says services from non-participating providers are not covered 
under open access unless preauthorized. 
 
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 provided on 
February 1, 2022, to February 15, 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 chiropractic services provided on March 4, 2022, by an out-
of-network provider. 
 
You asked the Plan to pay for chiropractic services. You say that you were uninformed of network issues at the 
time you enrolled with the plan. The Plan denied your request. The Plan says services from non-participating 
providers are not covered under your plan unless they are authorized by the plan before the services are 
provided. 
 
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 chiropractic services provided on March 4, 2022, 
by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro 2, Motion G Orthotic Device (CPT code 
L8702) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve MyoPro 2, Motion G Orthotic Device. You say that the device is necessary. 
The Plan denied your request. The Plan says MyoPro is considered investigational due to the lack of clinical 
evidence demonstrating an impact on improved health outcomes. 
 
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 MyoPro 2, Motion G Orthotic Device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the medical records indicate that the enrollee has a left sided 
hemiparesis secondary to cerebrovascular accident in 2012. The records provided do not include medical 
records from the ordering physician that establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 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 MyoPro 2, Motion G Orthotic Device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro 2, Motion G Orthotic Device (CPT code L8702) to be 
provided by an out-of-network provider.