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

 
We decided that the Plan does not have to reimburse you for chiropractic treatment, bilateral knee Ozone 
injections, Ketoralac, IT band, bilateral knee plasma rich protein treatments and laser treatment provided from 
September 8, 2021, through November 15, 2021. 
 
You asked the Plan to reimburse you for chiropractic treatment, bilateral knee Ozone injections, Ketoralac, IT 
band, bilateral knee plasma rich protein treatments and laser treatment. The Plan denied your request. The Plan 
says you must use network providers to get medical care and services when there are network providers 
available unless the services are an emergency or urgently needed services.  
 
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 Plan contract says that, with limited exceptions, members of the Plan must use network providers to get 
medical care and services. The only exceptions are emergencies, urgently needed care when the network is not 
available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the 
Plan authorizes the use of out-of-network providers. You can find this information on page 30 of the Plans 
2021 Evidence of Coverage. 
 
The records show that bilateral knee Ozone injections, Ketoralac, IT band, bilateral knee plasma rich protein 
treatments and laser treatment at issue are not manual manipulation of the spine. 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 reimburse you for chiropractic treatment, bilateral knee Ozone injections, Ketoralac, IT band, bilateral 
knee plasma rich protein treatments and laser treatment provided from September 8, 2021, through 
November 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a urinary catheter provided on September 
8, 2021. 
 
You asked the Plan to waive the coinsurance for a urinary catheter. You say that prior to starting with the Plan 
you confirmed that your catheters were covered. You also say they should be covered under home infusion 
therapy. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 20% 
coinsurance for in-network covered equipment and supplies.  
 
 
 
 
 
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$763.20, which is 20% coinsurance for a urinary catheter ($3,816 allowed amount x 20% coinsurance = 
$763.20). A urinary catheter 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 the coinsurance for a urinary catheter provided on September 8, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 microprocessor knee (L5848, L5845, L5828, and 
L5856). 
 
You asked the Plan to pre-approve a K3 microprocessor knee (L5848, L5845, L5828, and L5856). You say that 
the requested K3 microprocessor knee (L5848, L5845, L5828, and L5856) is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested K3 microprocessor 
knee (L5848, L5845, L5828, and L5856). 
 
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 a K3 microprocessor knee (L5848, 
L5845, L5828, and L5856). Our reviewer says that the enrollee does not meet criteria for the requested K3 
microprocessor knee (L5848, L5845, L5828, and L5856). Our physician reviewer found the K3 microprocessor 
knee (C-Leg, coded L5848 + L5845 + L5828 + L5856) exceeds the enrollee's medical needs and is not 
medically necessary. This is the enrollee's initial prosthesis, and the documentation does not support that he 
requires a heavier microprocessor knee. The enrollee has meniscal tears and is on Dilaudid and being referred 
to pain management for his knee pain. He was just started on Trelegy for emphysema noted on his chest CT. 
There was no physical exam by the physician documentation and the documentation does not clearly reveal 
why a mechanical knee would not be appropriate given its lighter weight. There is no evidence that the 
enrollee's needs cannot be effectively managed with a mechanical knee. The request for the C-leg exceeds the 
enrollee's medical needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a K3 microprocessor knee (L5848, L5845, L5828, and L5856) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a K3 microprocessor knee (L5848, 
L5845, L5828, and L5856).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on February 4, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the facility is responsible to obtain prior 
authorization and the service rendered was out of medical necessity. The Plan denied your request. The Plan 
says the rendering provider is an out-of-network 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 the physician services provided on February 4, 
2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you appear to be more stable and improving and should only require short-term 
additional acute care services that can be safely administered at the current facility until more appropriate for a 
lower level of care. There are no services at the LTACH that you require that are not already available and 
covered at the current facility. Transfer may be considered when treatment has completed. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital clinic visit provided on October 22, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hospital clinic visit. You say that you have requested in-network participation 
and would like for the services to be covered until it is obtained. The Plan denied your request. The Plan says 
the rendering provider is an out-of-network 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 hospital clinic visit provided on October 22, 
2021, 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 physician services provided on May 27, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that it is the facilities responsibility to obtain 
authorization and would like reimbursement for the service that was provided. The Plan denied your request. 
The Plan says the rendering provider is an out-of-network 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 the physician services provided on May 27, 2021, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service January 6, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 76700 
is a column II code to column I code 93976. 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 76700 billed for date of service January 6, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 17, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that your credentialing department is working on getting 
the Medicare product added to the existing contract for the providers, however that process has been taking 
some time. You also say that while they are working that out with the Plan, you are working on getting an 
authorization on file for futures dates of service. The Plan denied your request. The Plan says this provider is 
not a network provider with the plan and based on the documentation submitted, you have determined that the 
services rendered to the member are not urgent or emergent, nor were they approved in advance by a network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on December 17, 2021, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 20, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that prior authorization is required for lab services. 
 
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. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 20, 2021 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient substance abuse rehabilitation for the enrollee. 
 
You asked the Plan to pre-approve inpatient substance abuse rehabilitation. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that there is no indication that the need for 
monitoring of blood pressure treatment and seizure medication level represent ongoing severe withdrawal 
symptoms that requires continuous inpatient medical monitoring. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient substance abuse rehabilitation. 
Our reviewer says that inpatient substance abuse rehabilitation is not medically reasonable and necessary. It is 
not expected the enrollee will improve in a reasonable period of time as he is not showing any dangerousness to 
self or others, no auditory or visual hallucinations and no aggressive behaviors. The patient was compliant and 
cooperative with treatment. It does not appear medically necessary and reasonable to have psychiatric care 
provided at the acute inpatient level of care rather than a lower level of care as he does not have any suicidal or 
homicidal thoughts, hallucinations or aggressive behaviors. Our physician reviewer found that the enrollee's 
condition does not meet criteria for inpatient substance abuse rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient substance abuse rehabilitation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient substance abuse rehabilitation for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services rendered on December 6, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that procedure code 00813 is not separately payable. 
 
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. The Plan states that billed column II code 00813 has a modifier indicator of 0 
when billed with column I code 43249; however, there are no active National Correct Coding Initiative (NCCI) 
edits for this code pair. The Plan has not provided any documentation to support that the code is not payable as 
billed. Therefore, we decided that the Plan has to pay for the anesthesia services rendered on December 6, 
2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was not billed with the correct POS 
code. 
 The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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 the laboratory services provided on October 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiovascular stress test provided on 
November 23, 2021. 
 
You asked the Plan to waive the copayment for a cardiovascular stress test. You say that the doctor told you the 
procedure was erratic and that they wanted to do the test again. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing 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 $50 
copayment for in-network outpatient diagnostic tests, including stress tests in an office setting.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$50 copayment for a cardiovascular stress test. A cardiovascular stress test falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and 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 
the copayment for a cardiovascular stress test provided on November 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (99601) provided on October 2, 
2021. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code 99601 has a status indicator of I. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
 
We find that CPT code 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to 
pay for the home infusion therapy (99601) provided on October 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services provided to the enrollee on 
December 17, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the place of service was inappropriate for this procedure. 
 
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 99153 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service)." 
 
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 when procedures are reported without the technical component/professional component 
(TC/PC) modifier, then both the TC/PC would be paid for. In this case, the services would be reported with PC 
modifier, for the professional fee. 
 
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 moderate sedation services provided to the enrollee on December 17, 2021.