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

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on 
November 10, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as they were 
rendered by an ineligible provider. 
 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.    
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services in this case were provided by an 
acupuncturist who was not under the supervision of a physician, physician assistant, or a nurse 
practitioner/clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for the 
acupuncture treatment (97810, 97811) provided on November 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee appears 
to be stable and improving and should only require short-term additional acute care services that can safely be 
administered at the current facility until more appropriate for a lower level of care. He does not require services 
at the LTACH that are not already available at the current facility. There are no services at the LTACH that he 
requires that are not already available and covered at the current facility. LTACH services are not reasonable or 
medically necessary. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve ablation procedure. 
 
You asked the Plan to pre-approve genicular nerve ablation. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this procedure is 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 genicular nerve ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and radiofrequency ablations are considered investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve ablation procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided from January 19, 2021, to 
January 30, 2021. 
 
You asked the Plan to pay for skilled nursing services. You say that you should still receive payment for these 
claims as it took a year of you calling and doing everything you were told to do to receive payment. The Plan 
says the last day for timely filing of the claim was January 19, 2022, which is one year from the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 The record shows that a claim for skilled nursing services was not filed until January 20, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for skilled nursing services provided from January 19, 2021, to 
January 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan provided on April 13, 2022. 
 
You asked the Plan to waive the copayment for a duplex scan. You say that you should not have to pay for this 
scan. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 other outpatient diagnostic tests - radiological diagnostic services, not including x-rays.  
 
 
 
 
 
 
 You have been asked to pay the allowed amount of $94.60, which is less than the $120 for a duplex scan. A 
duplex scan falls within the Other Outpatient Diagnostic Tests - Radiological Diagnostic Services, Not 
Including X-Rays 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 duplex scan 
provided on April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided July 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services should be covered. The Plan denied 
your request. The Plan says medical records have not been supplied to determine medical necessity or how the 
enrollee came to the servicing provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lab services have been met. 
Specifically, medical records were not supplied to determine medical necessity. Therefore, we decided that the 
Plan does not have to pay for the lab services provided July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on April 
19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you disagree with the denial and 
request reconsideration of payment on this claim. The Plan denied your request. The Plan says prior 
authorization was not obtained by the OON 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 subsequent nursing facility care (99309) provided 
on April 19, 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 acupuncture services provided by a chiropractor on February 
15, 2022, and February 18, 2022. 
 
You asked the Plan to pay for acupuncture services. You say that you were forced to go to an acupuncturist 
near your home due to your pain being so severe. The Plan denied your request. The Plan says other services 
performed by a chiropractor are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for acupuncture services provided by a chiropractor on February 15, 2022, and 
February 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (99199 S9122) provided on April 12, 
2022 to April 27, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health 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 home health services (99199 S9122) provided on 
April 12, 2022 to April 27, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair repair services. 
 
You asked the Plan to pre-approve wheelchair repair services. You say that wheelchair repairs are necessary in 
this case. The Plan denied your request. The Plan says the enrollee's power wheelchair has exceeded the 
reasonable useful lifetime and no repairs will be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that during the reasonable useful lifetime, Medicare 
does cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment 
owned by the beneficiary. 
 
We looked at the file and Medicare rules. In this case, the record indicates that the power wheelchair in 
question was purchased in 2009. Therefore, the reasonable useful lifetime of this equipment has been exceeded 
and no repairs will be covered. Based on this information, we decided that Medicare rules for coverage of 
wheelchair repair services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
wheelchair repair services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection (62322) provided on January 25, 2022. 
 
You asked the Plan to pay for the injection (62322). The Plan denied your request. The Plan says procedure 
code 62322 is inclusive to procedure code 00865 and cannot be separately reimbursed. 
  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 62322 is a column II code to column I code 00865; however, 62322 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the injection (62322). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the procedure report does not include documentation to support the anesthesia was not dependent on the 
injection for intraoperative pain management. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection (62322) have not been met. Therefore, we decided that the Plan 
does not have to pay for the injection (62322) provided on January 25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from June 15, 
2021, to July 15, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the incorrect date of service was billed.  
The Plan must follow Medicare rules. Medicare rules say that home health services must be reported correctly.  
 
The "to date" in this case - July 15, 2021 - is not the 29th day of care. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does 
not have to pay for home health services provided to the enrollee from June 15, 2021, to July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 8, 
2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service February 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that the services rendered to this member could be 
delivered in an outpatient or short observation level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. You were diagnosed 
with atrial fibrillation and are planning an elective percutaneous transcatheter closure of left atrial appendage with endocardial implant procedure. You were recently documented as being asymptomatic without unstable 
conditions that might warrant prolonged inpatient recovery following the procedure. There was no suggestion 
you would require hospital services that would likely cross 2 midnights. Our physician reviewer found that 
your condition does not meet criteria for coverage of inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on April 5, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
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 wound care supplies provided on April 5, 2022 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80061, 82247, 82947, 83036, 84450, 
84550, 86803) provided on March 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you disagree with the denial and request 
reconsideration for payment on this claim. The Plan denied your request. The Plan says prior authorization was 
not obtained by the provider or facility. The provider should have verified the enrollee's eligibility, health 
benefits and obtained authorization prior to the visit before providing services to the enrollee. 
 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 services (80061, 82247, 82947, 83036, 
84450, 84550, 86803) provided on March 2, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on February 18, 
2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you should not be responsible for 
this because you were not told this would be outpatient surgery or that a copayment would be assessed. The 
Plan denied your request. The Plan says the cost share 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 $325 
copayment for a colonoscopy.  
 
 
 
 
 
 You have been asked to pay $325 for a colonoscopy. A colonoscopy falls within the Outpatient Surgery 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 provided on February 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (73522) provided on April 12, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the x-ray. 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 an x-ray (73522) provided on April 12, 2022 by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs provided April 27, 
2021, to January 18, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says the cost share has been 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 20% 
coinsurance for chemotherapy drugs.  
 
You have been asked to pay $5561.44 for chemotherapy drugs. Chemotherapy drugs fall within the Medicare 
Part B Prescription drugs benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan.  
 This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for chemotherapy drugs provided April 27, 2021, 
to January 18, 2022.  
 
 
 
Date of Service Billed Amount Plan Allowance Plan Paid Member 
Responsibility 
April 27, 2021 $13,676.55 $3870.42 $3,096.34 $774.08 
May 4, 2021 $13,676.55 $3870.42 $3,096.34 $774.08 
May 11, 2021 $13,676.55 $3870.42 $3,096.34 $774.08 
May 18, 2021 $13,676.55 $3870.42 $3,096.34 $774.08 
July 27, 2021 $13,676.55 $3748.92 $2,999.14 $749.78 
September 21, 2021 $13,676.55 $3748.92 $2,999.14 $749.78 
November 23, 2021 $13,676.55 $3527.76 $3,238.64 $289.12(out-of 
pocket met for 2021) 
January 18, 2022 $14,499.00 $3382.20 $2,705.76 $676.44 
Total    $5561.44