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

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service September 
28, 2021. 
 
You asked the Plan to pay for procedure code 99601. You say that you have provided records to support the 
services billed. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service September 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve occupational therapy. You say that these services are medically necessary. 
The Plan denied your request. The Plan says the requested services can be provided by a 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 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 
occupational therapy to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve continued treatment with Renflexis (Q5104). 
 
You asked the Plan to pre-approve Renflexis. You say that the requested drug is a medical necessity for you. 
The Plan denied your request. The Plan says that medical-necessity rules for continued treatment with the 
requested drug have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Renflexis. Our reviewer says that the 
requested drug is medically reasonable and necessary in this case. Our physician reviewer found that you have 
a diagnosis of rheumatoid arthritis. The Food and Drug Administration (FDA) has stated that the requested 
drug is indicated for your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Renflexis have been met. Therefore, we decided that the Plan has to pre-
approve continued treatment with Renflexis (Q5104).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical necessity rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a blood smear interpretation (85060) provided on February 9, 
2022. 
 
You asked the Plan to pay for a blood smear interpretation. You say that this service was rendered in an 
appropriate place of service. The Plan denied your request. The Plan says this service is not payable when 
performed for a hospital outpatient. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients. 
 
We looked at the file and Medicare rules. The record shows that the service at issue was furnished to a hospital 
outpatient and billed with code 85060. Based on this information, we decided that Medicare rules for coverage 
of a blood smear interpretation have not been met. Therefore, we decided that the Plan does not have to pay for 
a blood smear interpretation (85060) provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography received on March 21, 2022. 
 
You asked the Plan to pay for the fundus photography. You say that you disagree with the Plan's decision. The 
Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers routine eye exams. 
 
We looked at the file and the Plan's rules. Review of the file shows that the fundus photography is not part of 
the routine eye exam that is covered by the Plan. Based on this information, we decided that the Plan's rules for 
coverage of the fundus photography have not been met. Therefore, we decided that the Plan does not have to 
pay for the fundus photography received on March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatment services (98940, 
98941). 
 
You asked the Plan to pre-approve these services. You say that chiropractic treatment is medically necessary. 
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 the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 medically necessary. Our physician reviewer found that in this case, the record 
indicates that you have lumbar pain. The record does not provide documentation of a subluxation shown by  
x-ray or physical examination. The elements of the coverage criteria are not satisfied. The requested services 
are not 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chiropractic manipulative treatment services (98940, 98941).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hip orthosis (HO), abduction control of hip joint, 
postoperative hip abduction type, prefabricated, includes fitting and adjustment (L1686) and Addition to lower 
extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each (L2624) provided 
February 10, 2022. 
 
You asked the Plan to pay for the orthoses. You say that you have attached all supporting documentation. 
Please reprocess the claim. The Plan denied your request. The Plan says the request is not medically necessary 
because your records do not support the need or justification for the brace. 
 
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 pay for the orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee did not have a visit with the regarding bracing for the hip. 
There are no medical records describing the need a hip brace, nor the intent to order one. There is no 
commensurate note in the medical record on or around that date as to why these braces were being ordered. 
The review has determined that the items/services at issue in this case are not medically reasonable or 
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 orthoses have not been met. Therefore, we decided that the Plan does not 
have to pay for hip orthosis (HO), abduction control of hip joint, postoperative hip abduction type, 
prefabricated, includes fitting and adjustment (L1686) and Addition to lower extremity, pelvic control, hip 
joint, adjustable flexion, extension, abduction control, each (L2624) provided February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutments on tooth #18 and 19 (D6057) 
and abutment supported crowns on tooth #18 and 19 (D6059) provided on March 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel these services should be covered. The 
Plan denied your request. The Plan says custom fabricated abutments (D6057) and abutment supported crowns 
(D6059) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for custom 
fabricated abutments on tooth #18 and 19 (D6057) and abutment supported crowns on tooth #18 and 19 
(D6059) provided on March 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve Intracept procedure. You say that given the previously submitted history, 
physical examination and the radiologic findings, the intracept procedure is medically necessary and supported 
by strong science. The Plan denied your request. The Plan says the requested procedure does not meet the 
requirements for approval. 
 
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 Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the request is to perform the Intracept procedure to treat your pain, which is 
intraosseous destruction of the basivertebral nerve (BVN). There have been no specific studies done to identify 
that the BVN is the cause of your pain. The intracept procedure is experimental. More research is needed. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DME provided on March 21, 2022. 
 
You asked the Plan to pay for DME. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were 
they approved in advance. 
 
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 DME provided on March 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the coinsurance for a home ventilator provided on 
March 27, 2022. 
 
You asked the Plan to waive or reduce the coinsurance for the ventilator. You say that you can no longer afford 
the coinsurance. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 each durable medical equipment (DME) item, including oxygen equipment.  
 
You have been asked to pay $222.23, which is 20% of the allowed amount for the ventilator ($1,111.13 
allowed amount x 20% coinsurance = $222.23). The ventilator falls within the Durable Medical Equipment 
(DME) and Related 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 or reduce the coinsurance for a 
home ventilator provided on March 27, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to hold you harmless for lab services (80048, 85027) provided on February 23, 
2022. 
 
You asked the Plan to hold you harmless for lab services. You say that these services were referred by your 
provider and you only agreed to have them done because you were assured that they would be covered by your 
insurance. The Plan denied your request. The Plan says that these services were billed with an incorrect 
modifier and were performed by a provider who was not in-network at the time of services. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You say that you were referred for lab services by a contract provider. The Plan has not made any attempt to 
clarify if the referring provider is part of their network. The file does not show that the Plan provided notice 
that lab services would not be covered. Under Medicare rules, this means the lab services are considered 
approved by the Plan. In addition, the Plan denied these services on the basis that they were not billed 
according to Medicare regulations. As the enrollee, you are not responsible for billing issues between the 
provider and the Plan. Therefore, we decided that the Plan has to hold you harmless for lab services (80048, 
85027) provided on February 23, 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: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on May 17, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this provider was your primary 
care provider, and not a specialist. Therefore, you should not have to pay this copayment. 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 $40 
copayment for physician/practitioner services.  
 
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the 
Physician/Practitioner 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 
specialist visit provided on May 17, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to hold you harmless for lab services (85027, 80048, 84100, 83735) provided on 
February 22, 2022. 
 
You asked the Plan to hold you harmless for lab services. You say that these services were referred by your 
provider and you only agreed to have them done because you were assured that they would be covered by your 
insurance. The Plan denied your request. The Plan says that these services were billed with an incorrect 
modifier and were performed by a provider who was not in-network at the time of services. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You say that you were referred for lab services by a contract provider. The Plan has not made any attempt to 
clarify if the referring provider is part of their network. The file does not show that the Plan provided notice 
that lab services would not be covered. Under Medicare rules, this means the lab services are considered 
approved by the Plan. In addition, the Plan denied these services on the basis that they were not billed 
according to Medicare regulations. As the enrollee, you are not responsible for billing issues between the 
provider and the Plan. Therefore, we decided that the Plan has to hold you harmless for lab services (85027, 
80048, 84100, 83735) provided on February 22, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on November 3, 2021. 
 
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says the Plan offers hearing 
aids as an additional benefit to the member however the hearing aids must be ordered through the Plan's 
hearing provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plans 
hearing provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have 
not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on 
November 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel, 51 or greater 
genes (81455) provided February 13, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this test is a proven medically necessary covered 
benefit for comprehensive genomic profile testing for cancer. The Plan denied your request. The Plan says the 
targeted genomic sequence analysis panel, code 81455, is non-covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Genetic testing procedures submitted with code 81455 are unlikely 
to impact therapeutic decision-making in the clinical management of the patient and will be denied 
automatically as not medically necessary. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the targeted genomic sequence analysis panel, 51 or greater genes (81455) provided February 13, 2022.