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

 
We decided that the Plan does not have to pay for the chiropractic services provided from May 5, 2022, to June 
13, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic services. You say that you saw the enrollee prior to the dates of 
service, and you would like to appeal the denied claims. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no approved 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 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 chiropractic services provided from May 5, 
2022, to June 13, 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 an eye exam provided on May 3, 2022, by an OON provider. 
 
You asked the Plan to pay for an eye exam. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
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 eye exam provided on May 3, 2022, by an 
OON provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from April 22, 2022, to April 25, 
2022. 
 
You asked the Plan to pay for the medical services. You say that you believe this claim was not processed 
correctly. The Plan denied your request. The Plan says Original Medicare is responsible for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 8, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for medical services provided 
from April 22, 2022, to April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0037U) provided on May 3, 2022. 
 
You asked the Plan to pay for code 0037U. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We find that code 0037U is not supported in the medical record. Specifically, there is no documentation 
describing genetic testing on a sample collected on the date of service at issue. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (0037U) provided on May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for preventative medicine counseling and/or risk factor reduction 
intervention(s) provided to an individual, up to 15 minutes provided on February 22, 2022. 
 
You asked the Plan to pay for preventative medicine counseling and/or risk factor reduction intervention(s) 
provided to an individual, up to 15 minutes. The Plan denied your request. The Plan says preventative medicine 
counseling and/or risk factor reduction intervention(s) provided to an individual, up to 15 minutes has a value 
of zero and is not eligible for reimbursement. 
 
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 99401 is a column II code to column I code 99214 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for preventative medicine counseling and/or risk factor reduction intervention(s) 
provided to an individual, up to 15 minutes provided on February 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer bench for tub or toilet with or without 
commode opening (E0247). 
 
You asked the Plan to pre-approve a transfer bench. You say that the enrollee has trouble walking and getting 
around. The Plan denied your request. The Plan says a transfer bench is not a covered item/benefit with your 
Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a transfer bench for tub or toilet with or without commode 
opening (E0247).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service February 18, 
2022. 
 You asked the Plan to pay for procedure code 93010. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 93010 is bundled into payment for code 29505. 
 
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 93010 
is a column II code to column I code 29505. 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 93010 billed for date of service February 18, 
2022.
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 
November 13, 2021 to December 1, 2021. 
 
You asked the Plan to pay for home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
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, no RAP 
claim was submitted for these services. Therefore, we decided that the Plan does not have to pay for the home 
health services provided to the enrollee from November 13, 2021 to December 1, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for laboratory services provided on June 2, 2022. 
 
You asked the Plan to waive the coinsurance for laboratory services. You say that you received lab work within 
a clinic attached to the hospital. You say that you feel you should not have to pay for the services because you 
also have Medicaid. The Plan denied your request. The Plan says that the cost sharing will be applied according 
to the Plan contract. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $0 copayment for laboratory services.  
 
The Plan says you must pay 20% coinsurance for laboratory services. Based on the Plan contract, however, you 
cannot be asked to pay more than $0 copayment for laboratory services. Therefore, we decided that the Plan 
has to waive the coinsurance for laboratory services provided on June 2, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided on February 1, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says that medical records are needed to process this 
claim. 
 
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's sole basis for its denial is that medical records are needed 
to process the claim.  However, you did provide medical records along with your appeal request. It does not 
appear that the Plan ever reviewed these records.  The Plan has failed to provide any evidence showing why or 
if these records are deficient or why the records do not support medical necessity. The burden is on the Plan to 
support its denial and the Plan has failed to do so in this case. Therefore, we decided that the Plan has to pay for 
anesthesia services provided on February 1, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on March 30, 2022. 
 
You asked the Plan to pay for the electrocardiogram. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 
 
 
 
 
 We find that CPT code 93010 is not supported in the medical record. Specifically, coding guidelines state that 
many procedures require cardiopulmonary monitoring, either by the physician performing the procedure or an 
anesthesia practitioner. Since these services are integral to the procedure, they are not separately reportable. 
There is no separate interpretation report for the electrocardiogram. This service is included in the critical care 
services which were provided. Based on this information, we decided that Medicare rules for coverage of the 
electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for an 
electrocardiogram (93010) provided on March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that the in-network providers do not have 
the expertise that you need. The Plan denied your request. The Plan says the requested provider is an OON 
provider and there are multiple in-network providers that are qualified and are accepting new patients. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a podiatrist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the podiatrist office visit. You say that you did not like the prior physician, 
and you would like to see a different physician. The Plan denied your request. The Plan says the requested 
provider is an OON provider and there are multiple in-network providers that provide the same quality of 
service that the enrollee can see. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a podiatrist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound debridement services (11042) provided on May 17, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound debridement services. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
were non-emergent and prior authorization was not 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 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 wound debridement services (11042) provided on 
May 17, 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 the electrocardiogram (code 93010) provided on December 
22, 2021. 
 
You asked the Plan to pay for the electrocardiogram. You say that you believe the patient's other insurance is 
secondary and that the Plan should pay. The Plan denied your request. The Plan says the claim needs to be paid 
by the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified 
who the primary insurer is and has directed you to bill that primary insurer. As explained above, a Medicare 
Advantage Plan cannot be primary if the patient has other insurance (as is the case here.) As the secondary 
insurer, the Plan cannot be held responsible for the electrocardiogram until the primary insurer has denied the 
claim for these services. Therefore, we decided that the Plan does not have to pay for the electrocardiogram 
(code 93010) provided on December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of this 
device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a transthoracic echocardiography (TTE) 
test provided on February 15, 2022. 
 
You asked the Plan to reduce the copayment for TTE test. You say that this is classified as an "other outpatient 
diagnostic test" and not a radiology test. 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 $125 
copayment for Medicare-covered diagnostic radiology services. This TTE test is considered to be a diagnostic 
radiology service; therefore, the radiology copayment applies to this claim. 
 
You have been asked to pay $125 copayment for TTE test. This item/service 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 a transthoracic echocardiography (TTE) test provided on February 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for transfer to 
LTACH and that their current level of care cannot be adequately cared for at an SNF. The Plan denied your 
request. The Plan says criteria for admission to the LTACH have not been met. The enrollee's medical needs 
are being met in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a urology lab and ultrasound provided on 
June 15, 2022. 
 
You asked the Plan to waive the copayment for urology lab and ultrasound. You say that you should not have 
to pay this copayment, you already paid the provider. 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 outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $2.25 for the lab + $9.92 for the ultrasound = $12.17. This is less than the 
combined copayment of $30. This item/service 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 waive the copayment for a urology lab and ultrasound provided on June 
15, 2022.