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

 
We decided that the Plan does not have to pay for office visit provided on June 02, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says if the enrollee needs Medicare-covered medical care and a network provider is 
unable to provide this care, the enrollee may be able to get care from an out-of-network provider. Our plan 
must confirm there is not a network provider available and contact the plan to request authorization for the 
enrollee to obtain services from an out-of-network provider. If approved, the out-of-network provider will be 
issued an authorization to provide the service(s). 
 
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 office visit provided on June 02, 2022, by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service July 13, 
2022. 
 You asked the Plan to pay for procedure code 70480. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment for 
code 70450. 
 
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 70480 
is a column II code to column I code 70450. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70480 billed for date of service July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure 
(CPAP) provided on June 28, 2022. 
 
You asked the Plan to waive the coinsurance for CPAP. You say that you believe should not have to pay for the 
replacement CPAP. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for CPAP. The total allowed amount for the CPAP is $382.21. 
The required amount is $76.44 ($382.21 x 20% = $76.44). However, you are only being asked to pay $64.43 
which is less than the required amount. 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 a 
continuous positive airway pressure (CPAP) provided on June 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a walking boot provided on September 4, 
2021. 
 
You asked the Plan to waive the coinsurance for a walking boot. You say that you never got any equipment like 
that. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for a walking boot. The total allowed amount is $205.17. The 
amount you are being asked to pay is $41.03 ($205.17 x 20% = $41.03). 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 a walking boot provided on September 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would like reconsideration 
because the services are medical necessary. The Plan denied your request. The Plan says an LTACH admission 
is not medically necessary, and the enrollee's needs can be met in their current setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is not stable and requires short-term additional acute care that can 
safely be provided at the current facility. LTACH services is not 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 LTACH services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to issue reimbursement for the acupuncture treatment (97810) provided on 
January 28, 2022. 
 
You asked the Plan to issue reimbursement 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 that this case was not resolved in 
a timely manner. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided specific rationale for the denial issued in 
this case. The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we 
decided that the Plan has to issue reimbursement for the acupuncture treatment (97810) provided on  
January 28, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transesophageal echocardiography services (93312). 
 You asked the Plan to pre-approve transesophageal echocardiography services. You say that this procedure is 
medically reasonable for the enrollee's condition. The Plan denied your request. The Plan says the request is not 
medically necessary because the enrollee has not had a transthoracic echocardiogram (TTE) performed since 
the transient ischemic event, which could provide adequate information for treatment planning. 
 
The Plan follows Medicare rules. Medicare rules say that transesophageal echocardiography services are 
subject to the criteria listed 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 transesophageal echocardiography 
services. Our reviewer says that the requested services is not medically necessary at this time. Our physician 
reviewer found at issue is the appropriateness and medical necessity of a TEE, with negative and technically 
adequate TTE in October 2021, as well as a negative stress test. Clinical guidelines do not support carrying out 
a TEE in this setting. In summary, there is no supportive evidence for the medical necessity of a TEE in this 
this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transesophageal echocardiography services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transesophageal echocardiography services (93312).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on April 8, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you treated this patient in good faith, and they needed 
these tests. Please reconsider. The Plan denied your request. The Plan says there was no preauthorization by a 
primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and 
this was not an emergency. Therefore, the decision is upheld. 
 
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 drug testing provided on April 8, 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 new patient visit in facility provided on May 13, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for a new patient visit in facility. You say that this should be covered. The Plan 
denied your request. The Plan says there was no preauthorization by a primary care provider (this is different 
than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 new patient visit in facility provided on May 13, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular 
partial denture (D5214) provided by a participating provider. 
 
You asked the Plan to pre-approve a maxillary partial denture and a mandibular partial denture. You say that 
you would like these services covered. The Plan denied your request. The Plan says the requested services are 
not covered 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 pre-approve a 
maxillary partial denture (D5213) and a mandibular partial denture (D5214) provided by a participating 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist visit provided on April 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a specialist visit. You say that this patient needed these services, please 
reconsider. The Plan denied your request. The Plan says there was no preauthorization by a primary care 
provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 specialist visit provided on April 22, 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 the PureWick urine collection system. 
 
You asked the Plan to pre-approve the PureWick system. You say that you are unable to get up on the 
commode by yourself at night. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve the PureWick urine collection 
system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee can receive the care they need in another setting. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (88305, 88312) provided on July 21, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that specimens are sent to the lab for processing. The 
Plan denied your request. The Plan says this service is not covered when provided OON. 
 
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 lab services (88305, 88312) provided on July 
21, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve additional home health services. You say that additional home health 
services are medically necessary as you require assistance. The Plan denied your request. The Plan says the 
criteria for additional home health services have not been met. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health services. Our 
reviewer says that the requested home health services are not medically reasonable and necessary. Our 
physician reviewer found that you do not have documented skilled nursing needs. Laboratory blood draws are 
not in-and-of-themselves an indication for home health skilled nursing services.  As such, the requested, 
ongoing, home health skilled nursing services are not shown to be medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve five additional home health skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (87653, 87640, 87481, 87801) provided on 
April 21, 2022. 
 
You asked the Plan to pay for genetic testing. You say that attached are the medical records, requisition, test 
results, and appeal letter detailing that the PCR testing was medically necessary to ensure the enrollee's 
condition is treated swiftly and effectively. The Plan denied your request. The Plan says for a service to be 
covered under Medicare it must be reasonable and necessary. Tests must be safe and effective; not 
experimental or investigational; furnished in accordance with accepted standards of medical practice; ordered 
and furnished by qualified personnel; one that meets, but does not exceed, the patient's medical need; and at 
least as beneficial as an existing and available medically appropriate alternative. 
 
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. The records show that the requested testing does not meet the 
enrollees needs. Medicare rules say that services must be reasonable and necessary and not experimental or 
investigational. Based on this information, we decided that Medicare rules for coverage of genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (87653, 87640, 
87481, 87801) provided on April 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is at high risk for falling and is unsafe to 
go home where they live alone. You say that the enrollee requires intensive physical and occupational therapy 
to improve strength and endurance to return home safely. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and the enrollee's needs can be met at a lower level of care. 
 
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 there are no complex functional deficits specified that would require intense 
rehabilitation or interdisciplinary team management in an IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.