Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shower/bath chair provided on July 12, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for shower/bath chair. You say that you want to appeal the amount being charged. 
The Plan denied your request. The Plan says this service is not covered out-of-network. The enrollee is 
responsible for the entire cost. 
 
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 shower/bath chair provided on July 12, 2021, by 
an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on April 12, 2022, and 
April 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapy services. You say that you thought you had out-of-network coverage. 
The Plan denied your request. The Plan says the requested services are not covered when received from an 
OON 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 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 physical therapy services provided on April 12, 
2022, and April 21, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0483) provided to the 
enrollee on January 27, 2022. 
 
You asked the Plan to pay for the services. You say that you are not able to pay this. The Plan denied your 
request. The Plan says the documentation does not support that a quantitative test was completed on this date of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed." 
 
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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that in the case of this patient, a 
request for coverage for definitive drug testing reportedly performed on Jan 27, 2022. However, the provided 
documentation did not include evidence of an order or progress note from the time of this testing to show that it 
was clinically indicated or even performed on this date to support this request.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (procedure code G0483) provided to the enrollee on January 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel provided on 
January 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for targeted genomic sequence analysis panel. You say that you would like to 
request reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
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 targeted genomic sequence analysis panel 
provided on January 18, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a remote interrogation device evaluation (G2066, 93298) 
provided on March 30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a remote interrogation device evaluation (G2066, 93298). You say that current 
procedural terminology (CPT) codes 93298 and G2066 do not require any referral number and are always paid. 
The Plan denied your request. The Plan says this provider is a network provider with the Plan. The Plan also 
says that they have 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 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 a remote interrogation device evaluation (G2066, 
93298) provided on March 30, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on May 18, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that the enrollee has established care with the clinic, and you 
would like the claim reprocessed. The Plan denied your request. The Plan says the rendering and referring 
providers are both OON providers and there was no approved authorization. Also, the service rendered was not 
urgent or emergent. 
 
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 provided on May 18, 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 the x-ray exam of the cervical spine (72040) and the x-ray 
exam of the lumbar spine (72100) provided on June 20, 2022. 
 
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 these services are not covered under the Plan's 
contractual policy or by Medicare. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the x-ray exam of the cervical spine (72040) and the x-ray exam of the 
lumbar spine (72100) provided on June 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 sensors (A9276). 
 
You asked the Plan to pre-approve a Dexcom G6 sensors. You say that the requested sensors are medically 
necessary for the enrollee. The Plan denied your request. The Plan says the provider did not send a statement 
that explains why the enrollee cant use the preferred product. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The file does not include any documentation from your physician 
documenting why you require this specific brand of test strips. Without this, medical necessity cannot be 
established. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 sensors 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 sensors 
(A9276).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is myelopathic and needs assistance with 
walking. The Plan denied your request. The Plan says that the request is not medically necessary. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation shows that there is an IRF compliant diagnosis. The enrollee has active 
comorbidities/hospital complications that would require continued medical monitoring on inpatient basis 
during rehabilitation. Evaluating therapists show that the enrollee can tolerate intense therapy and recommend 
intense therapy thus IRF criteria have been met. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
IRF admission and services.  
 
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 pay for the office visit (99215) provided on June 14, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service should be 
covered. The Plan denied your request. The Plan says payment cannot be made to providers that have opted out 
of Medicare. 
 
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 the office 
visit (99215) provided on June 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Negative Pressure Wound Therapy (NPWT), 
debridement, repair, complex, trunk, and implantation of biologic implant for soft tissue reinforcement. 
 
You asked the Plan to pre-approve NPWT, debridement, repair, complex, trunk, and implantation of biologic 
implant for soft tissue reinforcement. You say that the services are necessary. The Plan denied your request. 
The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met. 
 
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 NPWT, debridement, repair, complex, 
trunk, and implantation of biologic implant for soft tissue reinforcement. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is insufficient evidence to support that the use of Epifix is medically reasonable and necessary in 
the requested setting. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of NPWT, debridement, repair, complex, trunk, and implantation of biologic 
implant for soft tissue reinforcement have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Negative Pressure Wound Therapy (NPWT), debridement, repair, complex, trunk, and 
implantation of biologic implant for soft tissue reinforcement.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
January 10, 2022, to January 12, 2022. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG and secondary diagnosis code is not 
supported. 
 
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 073 (CRANIAL AND PERIPHERAL 
NERVE DISORDERS 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 
inpatient hospital services at the DRG originally billed. Our reviewer says that the services at issue in this case 
were not supported by the medical records. Our physician reviewer found that although the provider 
documented metabolic encephalopathy and vasomotor nephropathy, reasonable support within the health 
record was not documented. The review has determined that DRG 074 (CRANIAL AND PERIPHERAL 
NERVE DISORDERS WITHOUT MCC) was more supported in the records. The records did not support the 
use of secondary diagnosis code G93.14 - metabolic encephalopathy and N17.0 - acute kidney failure with 
tubular necrosis.  
 
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 from January 10, 2022, to January 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan provided on May 26, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the CT scan. You say that it was medically necessary to provide the service to 
the enrollee. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
was no referral from an in-network provider or an approved authorization. Also, the service rendered was not 
urgent or emergent. 
 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 a CT scan provided on May 26, 2022, by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy provided on May 27, 2022, to 
June 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home infusion therapy. You say that it was medically necessary to provide 
the enrollee with services and you would like the claim paid. The Plan denied your request. The Plan says the 
rendering and referring providers are both OON providers and there was no approved authorization. Also, the 
service rendered was not urgent or emergent. 
 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 home infusion therapy provided on May 27, 
2022, to June 2, 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 medical examination and evaluation provided on June 
6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an eye medical examination and evaluation. You say that this provider regularly 
complies with all administrative requirements for payments. The Plan denied your request. The Plan says this 
provider is a network provider with the Plan. The Plan also says that these services were not 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 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 medical examination and evaluation 
provided on June 6, 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 a periodic comprehensive preventive medicine reevaluation 
provided on July 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a periodic comprehensive preventive medicine reevaluation. You say that this 
provider regularly complies with all administrative requirements for payments. The Plan denied your request. 
The Plan says this provider is not a network provider with the Plan. The Plan also says that these services were 
not 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 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 a periodic comprehensive preventive medicine 
reevaluation provided on July 7, 2022, by an out-of-network (OON) provider.