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

 
We decided that the Plan does not have to pay for the office visit (99215) provided on June 1, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that you saw this provider in 
August and September of 2021. You say that both of those claims were paid. You also say that this claim 
should be paid. 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 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 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 office visit (99215) provided on June 1, 2022, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 1, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed with an incorrect place of service. 
 
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. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology provided on July 05, 2022. 
 
You asked the Plan to pay for oncology. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for oncology provided on 
July 05, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle-foot orthosis (AFO) provided on April 12, 2022. 
 
You asked the Plan to pay for AFO. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says the enrollee received an identical AFO on November 8, 2018; therefore, this 
replacement orthosis is not supported for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement due to wear is not covered during 
the reasonable useful lifetime of durable medical equipment.  
 
We looked at the file and Medicare rules. The enrollee previously received an ankle-foot orthosis on November 
8, 2018. This item was still within the reasonable useful lifetime. The record does not show that this item had 
sustained irreparable damage. Based on this information, we decided that Medicare rules for coverage of AFO 
have not been met. Therefore, we decided that the Plan does not have to pay for an ankle-foot orthosis (AFO) 
provided on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for radiation therapy, physician services and 
guidance imaging provided from November 4, 2021, to December 14, 2021. 
 
You asked the Plan to waive the cost share for radiation therapy, physician services and imaging guidance. You 
say that this should be covered. 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 20% 
coinsurance for therapeutic radiology, a $35 copayment for physician specialist services and a $15 copayment 
for imaging guidance.  
 
 
You have been asked to pay a total of $2,243.21 for the radiation therapy, physician services and imaging 
guidance. The radiation therapy and imaging guidance fall within the Outpatient diagnostic tests and 
therapeutic services and supplies benefit category. The physician services fall within the Physician/Practitioner 
services, including doctors 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 cost share 
for radiation therapy, physician services and guidance imaging provided from November 4, 2021, to December 
14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 05, 2022. Therefore, 
we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided on May 06, 2022, to August 08, 2022. 
 
You asked the Plan to pay for office visits. You say that you did not know the provider is out-of-network. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visits provided on 
May 06, 2022, to August 08, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Kerendia tablet. 
 
You asked the Plan to pre-approve Kerendia. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Kerendia 
tablet.  
 Benefits for Kerendia may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to waive the copayment for ambulance transport provided on June 27, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this should be covered. The 
Plan denied your request. The Plan says that 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 does not say in clear and accurate terms 
how much you should expect to pay for Ambulance services.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must $100 
copayment for ambulance services. The Plan contract does not clearly say how much enrollees must pay for 
Ambulance services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing 
information. Therefore, we decided that the Plan has to waive the copayment for ambulance transport provided 
on June 27, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from April 1, 2022, to April 30, 
2022. 
 
You asked the Plan to pay for home health care. You say that the enrollee was not re-admitted. The Plan denied 
your request. The Plan says this claim was not billed with the appropriate admission date. 
 
The Plan must follow Medicare rules. Medicare rules say that for beneficiaries receiving home health services 
in 2021 that will continue in 2022, the home health agency shall use a one-time artificial admission date 
corresponding to the From date of the first period of continuing care in 2022.  
 
We looked at the file and Medicare rules. This claim did not use a one-time artificial admission date 
corresponding to the From date of the first period of continuing care in 2022. Based on this information, we 
decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the 
Plan does not have to pay for home health care provided from April 1, 2022, to April 30, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve multiple leg procedures on the left leg arteries (angioplasty, 
atherectomy, stents). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the doctor has not tried a conservative treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is satisfactory documentation that the patient has significant peripheral artery disease of the left 
lower extremity with angiographic evidence of a high-grade stenosis of the left superficial femoral artery. 
There is documentation that the patient has 8 out of 10 pain with walking that is not relieved by rest. The 
patient has a history of diabetes that may, in part, be responsible for an artificially elevated ankle brachial index 
(ABI). Additionally, if the previous treatment on the right was for claudication, she would not be able to 
experience meaningful benefit from that treatment if her walking is now limited by the left leg.  In summary, 
there is satisfactory documentation to support the medical necessity of endovascular treatments of the left lower 
extremity arteries. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve multiple leg procedures on the left leg arteries (angioplasty, atherectomy, stents).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Covidien Dover catheters provided on 
August 10, 2022. 
 
You asked the Plan to waive the coinsurance for Covidien Dover catheters. You say that you are disputing the 
share cost. 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 18% 
coinsurance for durable medical equipment and related supplies. The allowed amount of this Covidien Dover 
catheters total $129.60, resulting in a coinsurance amount of $23.33. 
 
You have been asked to pay 18% coinsurance for Covidien Dover catheters. This item/service falls within the 
durable medical equipment 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 Covidien Dover catheters provided on August 10, 2022.  
 Your complaint about getting different supplies is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic repetitive transcranial magnetic stimulation 
(TMS). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria has not been met, as there has not been complete outpatient therapy at an 
intense enough frequency, nor has there been the requirement amount of medication trials during the current 
episode of depression. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that you have not been tried on four psychopharmacologic agents from two different classes and there is 
no documentation of psychotherapy. The criteria is not 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve therapeutic repetitive transcranial magnetic stimulation (TMS).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued stay for inpatient behavioral health care. 
 
You asked the Plan to pre-approve continued stay for inpatient behavioral health care. You say that the 
provider and the State of New Mexico do not believe that the enrollee would be able to function at a lower 
level of care. The Plan denied your request. The Plan says the request does not meet Medicare guidelines 
because records do not show that the enrollee had dangerous behaviors within the past 24 hours, inability to 
complete activities of daily living, or serious mediation side effects. Continued stay at the inpatient behavioral 
health level of care for this admission is not medically necessary beginning December 28th, 2022. 
 
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 continued stay for inpatient behavioral 
health care. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee was compliant with treatment while not showing any acute threats to safety. It did 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 beyond the dates in question as she did not have dangerousness to self or others and 
was compliant with her treatment. The health plans denial of continued inpatient psychiatric services is 
appropriate. The enrollee did not appear to require inpatient mental health treatment beyond the date in 
question as she was not a danger to herself or others and does not have auditory or visual hallucinations. It did 
not appear that active treatment was taking place beyond the date in question. It did not appear that the services 
were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in 
question. I am unable to find an individualized treatment plan however, the entire record is not present. It did 
appear that the records were supervised and evaluated by a physician. Based upon review the records provided 
for the admission of this enrollee does not meet the criteria for December 28, 2022, forward as this enrollee 
was not shown to be a danger to herself or others, delusions, auditory or visual hallucinations noted. She was 
cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued stay for inpatient behavioral health care. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continued stay for inpatient behavioral health 
care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 5, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 76705 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 76705 
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 76705 billed for date of service August 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found documentation shows that you have complex functional impairments however there 
are no active medical issues specified thus the complexity of your documented nursing, medical and 
rehabilitation needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 09, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on September 09, 2022.