Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-certification for home health services provided on 
February 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for re-certification for home health services. You say that you provided necessary 
services in good faith as this was a medical necessity. You are appealing with supporting records and request 
reconsideration of payment. The Plan denied your request. The Plan says the enrollee must receive care from a 
network 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 re-certification for home health services provided 
on February 11, 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 cognitive assessment and care plan services provided on 
May 12, 2022. 
 
You asked the Plan to pay for cognitive assessment and care plan services. You say that the services were 
rendered to the member at an assisted living facility (ALF) and the ALF is responsible for obtaining prior 
authorization for all their patients, which should also cover for the medical treatments provided by this doctor 
as it was rendered in good faith. The Plan denied your request. The Plan says the services were not urgent or 
emergent and the services could have been rendered by a Plan participating provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for cognitive assessment and care plan services provided on  
May 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory readings from surgery provided on June 30, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory readings from surgery. You say that the beneficiary never came into 
the office, this was necessary should be covered. The Plan denied your request. The Plan says there was no 
preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 laboratory readings from surgery provided on June 
30, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75710 billed for services provided on March 
9, 2022. 
 
You asked the Plan to pay for the services provided. You say that the service should be paid separately. The 
Plan denied your request. The Plan says the code cannot be verified. 
 
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 75710 is angiography, extremity, unilateral, radiological 
supervision and interpretation. We find that CPT code 75710 is not supported. The angiography services are 
included in the revascularization procedure (code 37225). The records do not indicate the angiography was an 
unusual service. Providers shall bill the most comprehensive code that describes the services provided. Based 
on this information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 75710 billed for services provided 
on March 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that you are not better, and you need 
the physical therapy that is provided at the SNF. The Plan denied your request. The Plan says the enrollee does 
not meet the Medicare criteria for SNF care, and the enrollee can receive the services they need with long term 
care. 
 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 
requested SNF care after October 30, 2022, is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found that there are no identifiable skilled nursing service needs 
and there are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or 
therapy services on a daily basis. This enrollee does 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuation of SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in home physical therapy visits provided 
from December 15, 2021, to February 16, 2022. 
 
You asked the Plan to waive the copayment for in home physical therapy visits. You say that these 
appointments were in your home and therefore should not have a copayment. 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 $25 
copayment for physical and occupational therapies. You had 16 appointments, resulting in a $400 total 
copayment ($25 copayments x 16 visits = $400 total). 
 
You have been asked to pay a $400 copayment for in home physical therapy visits. This item/service falls 
within the physical and occupational therapies 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 in home physical therapy visits provided from December 15, 2021, to February 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic testing on April 26, 2022. 
 
You asked the Plan to waive the copayment for diagnostic testing. You say that you want to appeal the amount 
being 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 $50 
copayment for Medicare-covered diagnostic procedures and tests (e.g., allergy test or EKG). Covered services 
include but are not limited to other outpatient diagnostic tests - Non-radiological diagnostic services (e.g., 
allergy test or EKG). The provider billed in the amount of $50 and the allowed amount is $35.57. This is less 
than the copayment amount. Therefore, resutls in the total cost sharing amount of $35.57. 
 
 
 
 
 You have been asked to pay a $35.57 copayment, which is less than the copayment for diagnostic testing. This 
item/service falls within the Outpatient diagnostic test 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 waive the copayment for diagnostic testing on April 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM) 
and supplies. 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM and supplies. You say that you prick your finger 
three to four times a day and it hurts your fingers. The Plan denied your request. The Plan says you do not meet 
criteria for the requested device. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre continuous glucose monitor (CGM) and supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TriVisc. 
 
You asked the Plan to pre-approve TriVisc. You say that you need the requested injections to help with your 
pain. You say that you currently cannot walk. The Plan denied your request. The Plan says the records do not 
show that the enrollee has a history of failure, contraindication or intolerance to the preferred drugs. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 TriVisc. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of Synvisc, 
Durolane, and Gelsyn-3 before they will approve the requested drug. The provided records do not indicate that 
the enrollee has tried and failed the Plan's preferred step-one alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the Plan's preferred step-one 
alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TriVisc have not been met. Therefore, we decided that the Plan does not have to 
pre-approve TriVisc.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on April 12, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you are appealing the 
outpatient hospital copayment applied toward claim number 22B262963000 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 $475 
copayment for outpatient hospital services. 
 
You have been asked to pay a $475 copayment for outpatient surgery. This item/service falls within the 
outpatient hospital 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 outpatient 
surgery provided on April 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for an EKG, a heart ultrasound, and a 
specialist office visit provided on August 10, 2021. 
 
You asked the Plan to reduce the copayments for an EKG, a heart ultrasound, and a specialist office visit. You 
say that you are disputing the claim for a long overdue payment for a visit on August 10, 2021. 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 $30 
copayment for non-radiological diagnostic services, including an EKG. Your contract with the Plan also states 
that you must pay a $160 copayment for in-network radiological diagnostic services, including ultrasounds, 
performed in a physicians office or at a free-standing facility. Your contract with the Plan also says that you 
must pay a $40 copayment for services obtained from an in-network specialist, or under certain circumstances, 
treatment by a nurse practitioner or physicians assistant or other non-physician health care professionals in a 
specialists office. 
 
You have been asked to pay $11.60 for an EKG, which is less than the standard $30 copayment. You have been 
asked to pay $160 for an ultrasound. You have been asked to pay $45 for a specialist office visit. The total you 
owe is $216.60 ($11.60 + $160 + $45 = $216.60). The EKG and ultrasound fall within the outpatient diagnostic 
tests and therapeutic services and supplies benefit category. The specialist office 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 reduce the copayments for an EKG, a heart ultrasound, and a specialist office visit provided on August 10, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services (97110 x 4) provided on 
September 4, 2021. 
 
You asked the Plan to pay for the PT services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the billed services are 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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the record indicates that the 
services took place in the enrollee's home and that they are homebound. Based on this information, we decided 
that Medicare rules for coverage of the PT services have not been met. Therefore, we decided that the Plan 
does not have to pay for the physical therapy (PT) services (97110 x 4) provided on September 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve group 3 power wheelchair with multiple power options, 
power tilt and recline (K0861, E1012, E2313, E1007, E0953, E2359, E2311, E1028, E2605, E2377).  
You asked the Plan to pre-approve the power wheelchair. You say that you are requesting an appeal for the 
enrollee's power wheelchair. See revised clinic notes for the appeal. The Plan denied your request. The Plan 
says the enrollee does not have a medical need for multiple power options included with K0861 group 3 power 
wheelchair. The upgraded electronics cannot be covered as it is not medically necessary to control the power 
options through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has progressive neurological impairment and progressive inability to 
walk. The enrollee has a relatively preserved upper body strength at 4-5/5 with arm flexion and extension and 
wrist flexion and extension. The enrollee does not require a group 3 wheelchair. The enrollee does not require a 
ventilator, use intermittent catheterization, or have a high risk for skin breakdown. Since the requested 
wheelchair is not reasonable and necessary, none of the requested accessories can be covered. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve group 3 power wheelchair with multiple power options, power tilt and recline 
(K0861, E1012, E2313, E1007, E0953, E2359, E2311, E1028, E2605, E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014), and an 
eye refraction (92015) provided on May 23, 2022. 
 
You asked the Plan to waive the copayment for a medical eye examination, and an eye refraction. You say that 
you should not have a copayment for the services. 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 a medical eye examination.  
 
You have been asked to pay a $40 copayment for a medical eye examination, and an eye refraction. This 
item/service falls within the vision 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 medical eye examination (92014), and an eye refraction (92015) provided on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for an office visit provided on April 13, 2022. 
 
You asked the Plan to reduce the deductible for an office visit. You say that you should only be responsible for 
a $15 copayment 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 
$142.80 deductible for an office visit. 
 
You have been asked to pay a $142.80 deductible for an office visit. This item/service falls within the an office 
visit 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 deductible for an office visit provided on April 
13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 1, 2022, billed with 
codes 81162, 81201, 81314, 81334, 81351 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare coding regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 1, 2022, billed with codes 81162, 81201, 81314, 81334, 81351 and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 23, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
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 laboratory services related to end-stage renal disease (ESRD) provided on June 23, 
2022.