Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81455) provided May 7, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the code billed is not eligible for payment for this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code 81450 is a useful representation 
of the aggregate of these gene tests and may be used as long as the panel contains, at a minimum, 5 or more 
gene tests for molecular biomarkers determined to meet Medicare coverage criteria. 
 
We looked at the file and Medicare rules. Procedure code 81455 was billed for this service and not 81450. 
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 genetic testing (81455) provided May 7, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on September 18, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on facility staff to verify 
eligibility and obtain authorization from the insurance company. The Plan denied your request. The Plan says 
no prior authorization was 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on September 18, 2021, by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computed tomographic angiography, head and neck, 
with contrast material(s), including non-contrast images, if performed, and image postprocessing Computed 
tomographic angiography (70496, 70498) provided February 13, 2021. 
 
You asked the Plan to pre-approve the diagnostic service. You say that the claim denied as duplicate. Please 
find the attached medical records and reconsider this claim for payment. The Plan denied your request. The 
Plan says services were paid to another provider. With the information provided, the Plan is unable to 
determine how the enrollee came to the servicing provider or whether the services are medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 computed tomographic 
angiography, head and neck, with contrast material(s), including non-contrast images, if performed, and image 
postprocessing Computed tomographic angiography (70496, 70498) provided February 13, 2021. have been 
met. the records show that the Plan made multiple attempts to obtain medical records from the provider without 
success. Therefore, we decided that the Plan does not have to pre-approve the computed tomographic 
angiography, head and neck, with contrast material(s), including non-contrast images, if performed, and image 
postprocessing Computed tomographic angiography (70496, 70498) provided February 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyewear provided on October 30, 2021. 
 
You asked the Plan to pay an additional amount for the eyewear. You say that you are on a restricted income 
and cannot afford the coinsurance. The Plan denied your request. The Plan says the benefit of $150.00 was 
applied for services rendered. 
 
 Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services up to 150.00 for eyeglasses or contact lenses every year. 
 
We looked at the file and the Plan's rules. The file shows that the Plan paid the maximum eyewear benefit of 
150.00 for the eyewear. Therefore, we decided that the Plan does not have to pay an additional amount for the 
eyewear provided on October 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on December 7, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on  
December 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on September 25, 
2021. 
 You asked the Plan to pay for therapeutic exercises. You say that these services were medically necessary and 
were billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical 
Therapy Assistant. There is no indication that the Nurse Practitioner was present on site while the therapy 
services were being rendered. The incident-to requirements have not been met in this case. Based on this 
information, we decided that Medicare rules for coverage of therapeutic exercises have not been met. 
Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on 
September 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee provided 
to the enrollee from June 6, 2021, to June 23, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the DRG was updated in this case.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 853 (INFECTIOUS AND PARASITIC 
DISEASES WITH O.R. PROCEDURE WITH MCC). 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 services. Our reviewer says that the services at issue in this case were not supported by the medical 
records. Our physician reviewer found the enrollee was admitted and treated in the hospital after arriving 
unresponsive, hyperthermic, and requiring fluids but complicated by fluid overload and chronic obstructive 
pulmonary disease (COPD) requiring intubation and vasopressors. She was diagnosed with heat stroke, 
dehydration and responded to early treatment with fluids. She was also diagnosed with pneumonia vs. COPD 
exacerbation, and acute respiratory failure requiring steroids and was extubated successfully. Antibiotics were 
not continued. There was no O.R. procedure noted in the record or other information provided to support the 
DRG 853. DRG 871 is more appropriate for this hospital stay.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee provided to the enrollee from June 6, 2021, to June 23, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nerve stimulation treatment for the enrollee. 
 
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied 
your request. The Plan says the documentation received indicates that the enrollee neurogenic bladder is due to 
diabetes and a transient ischemic attack. 
 The Plan must follow Medicare rules. Medicare rules say that there are specific indications for sacral nerve 
stimulation for urological purposes. If these diagnoses are related to diabetes, then the treatment is not covered. 
 
The enrollee's urological diagnosis is due to diabetes. Based on this information, we decided that Medicare 
rules for coverage of the treatment have not been met. Therefore, we decided that the Plan does not have to pre-
approve nerve stimulation treatment for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the subcutaneous tissue debridement 
(11042) provided from August 4, 2021, through August 23, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $250 
copayment for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical 
center, including but not limited to hospital or other facility charges and physician or surgical charges.   
You have been asked to pay $750 ($250 copayment x 3) for the Medicare-covered surgeries provided at an 
outpatient hospital on August 4, 2021, August 16, 2021, and August 23, 2021. 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 copayments for the subcutaneous tissue debridement (11042) provided from August 4, 2021, 
through August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on 
October 19, 2021. 
 
You asked the Plan to pay for the dental services. You say that you found this provider on the plan's website in 
April. You say that you received a letter after your appointment advising the provider was not in network. You 
say that you in October the same office advised they worked things out with the Plan and were in network. You 
also say that you received another letter advising the provider is not in network. The Plan denied your request. 
The Plan says the provider in this case is out of network. The Plan says the claim was processed correctly. The 
Plan also says that you did not contact them to verify benefits or provider eligibility. 
 
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 and the services are listed as covered, 
the out of network dentist, the coinsurance level will apply to the average negotiated in network fee schedule 
(INFS) in your area. Members are responsible for the difference between the INFS and dentists charged fees. 
Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) 
provided on October 19, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not have a need for intravenous 
medications, new tube feeding, ostomy care or daily complex wound care. You are walking greater than 
household distances with a wheeled walker at supervision level and is supervision for transfers. You do not 
require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with 
home health care or in a long-term care facility on a part time basis appear appropriate in this case. 
 
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 skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not have a need for intravenous 
medications, new tube feeding, ostomy care or daily complex wound care. You are walking greater than 
household distances with a 2-wheeled walker with modified independence and is modified independent for 
transfers. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. 
Services in the home with home health care or in a long-term care facility on a part time basis appear 
appropriate in this case. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 31, 
2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you never saw this doctor and do 
not even know who this doctor is. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for specialist visits.  
 
The medical records show that you had a specialist visit on August 31, 2021. Therefore, you are responsible to 
pay the $30 copayment.  You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's 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 waive the copayment for a specialist visit provided on August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) provided February 24, 
2021. 
 
You asked the Plan to pay for the office visit. You say that kindly review the attached medical records and 
request for processing the denied codes towards payment as soon as possible. The Plan denied your request. 
The Plan says evidence of misrepresented services. 
 
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 outpatient office visit (99202) 
provided February 24, 2021. have been met. there is no evidence of an established relationship between the 
enrollee and the physician. The records show that the Plan made multiple attempts to request medical records 
from the provider without success. Therefore, we decided that the Plan does not have to pay for the outpatient 
office visit (99202) provided February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services, medical examination and 
evaluation provided on November 3, 2021. 
 
You asked the Plan to pay for ophthalmological services, medical examination and evaluation. The Plan denied 
your request. The Plan says it is important to know which providers are part of our network because, with 
limited exceptions, while you are a member of our Plan you must use network providers to get your medical 
care and services. The only exceptions are emergencies, urgently needed services when the network is not 
available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes use of out-of-network providers. 
 
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 ophthalmological services, medical examination and evaluation 
provided on November 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that this is medically necessary. The Plan denied your 
request. The Plan says you can continue with the preferred drug, Kenalog. 
 
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 Zilretta. Our reviewer says that the 
requirements for coverage of Zilretta have not been met. Our physician reviewer found the Plan requires a trial 
of drug Kenalog before they will approve the requested drug. The records show that you have tried and had 
success with Kenalog. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services provided on November 8, 2021. 
 
You asked the Plan to pay for dermatology services. You say that your family has a history of skin cancer and 
the provider felt you should get checked as soon as possible. Another dermatologist was not available at the 
time. The Plan denied your request. The Plan says rules for payment have not been met because the provider at 
issue has opted out of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
dermatology services provided on November 8, 2021.