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

 
We decided that the Plan does not have to pay for laboratory services provided on May 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that this was a medical necessity. The Plan denied 
your request. The Plan says the rendering provider is a non-participating provider. The Plan also says that they 
did not authorize any services for this 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 laboratory services provided on May 9, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the office or other outpatient visit for 
the evaluation and management of an established patient (99212), allergen specific IgG quantitative or 
semiquantitative (86001), analysis for antibody bacteria (86609), and analysis for antibody to aspergillus 
(fungus) (86606) provided March 11, 2022. 
 
You asked the Plan to provide additional payment for the office visit, measurement of antibody (IgG) to 
allergic substance, analysis for antibody bacteria and analysis for antibody to aspergillus. You say that you would like the Plan to cover these costs. The Plan denied your request. The Plan says that the IgG antibody test 
is not covered under Medicare. The remaining services had the correct copayments applied. 
 
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 specialist office visits and a $10 copay for outpatient lab services. 
 
You have been asked to pay a $36.09 for the office visit. You have also been asked to pay a total of $10 for the 
analysis for bacterial and aspergillus antibodies. 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. The allergen specific IgG quantitative or semiquantitative test is not covered 
under Medicare. Therefore, we decided that the Plan does not have to provide additional payment for the office 
or other outpatient visit for the evaluation and management of an established patient (99212), allergen specific 
IgG quantitative or semiquantitative (86001), analysis for antibody bacteria (86609), and analysis for antibody 
to aspergillus (fungus) (86606) provided March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 26, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this code is payable. The Plan denied your 
request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
 We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited bilateral noninvasive physiologic studies provided on 
April 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for limited bilateral noninvasive physiologic studies. You say that you are appealing 
the claim payment denial. The Plan denied your request. The Plan says the services were provided out-of-
network and were not approved in advanced. 
  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 limited bilateral noninvasive physiologic studies 
provided on April 20, 2022, by an out-of-network (OON) provider.
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 member needs physician oversight, physical and 
occupational therapy and 24 hour nursing care. The Plan denied your request. The Plan says that the services 
you need can be provided safely in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for encephalopathy. Your medical 
problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that your condition does not meet Medicare criteria for IRF 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on May 11, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you have never had a no transport service 
billed to your credit in previous years. You also say that you would never call the ambulance back-to-back so 
close. The Plan denied your request. The Plan says since there was no transport was provided, there is no 
payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
 
 
 
 
 
 
 The ambulance company did not provide transport services on May 11, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on May 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a direct skilled nursing service of a registered nurse provided 
on March 21, 2022, by an OON provider. 
 
You asked the Plan to pay for a direct skilled nursing service of a registered nurse. You say that you are 
requesting reconsideration stating the claim was denied for a duplicate submission. The Plan denied your 
request. The Plan says the out-of-network services were not authorized. 
 
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 direct skilled nursing service of a registered 
nurse provided on March 21, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right hip subchondroplasty (SCP) with injection of 
Accufill bone substitute material (manipulated and cannulated screw). 
 
You asked the Plan to pre-approve the SCP with Accufill. You say that the enrollee has trialed physical 
therapy, medications, and steroid injections with only partial relief. You say that the enrollee does not wish to 
have surgery at this time. You also say that you have had success with this procedure for many of your patients. 
The Plan denied your request. The Plan says the requested treatment is not the standard of care for the 
enrollee's condition. 
 
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 SCP with Accufill. Our reviewer 
says that the requested SCP with Accufill is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that 
shows this request to be an effective and/or safe treatment for the noted pathology. As documented in the above 
peer-reviewed literature, additional studies are needed for this procedure, (as they have not been large, long-
term with positive results.)  There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested right hip subchondroplasty with injection of Accufill 
bone substitute material, in this case, is not medically reasonable or 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 SCP with Accufill have not been met. Therefore, we decided that the Plan 
does not have to pre-approve right hip subchondroplasty (SCP) with injection of Accufill bone substitute 
material (manipulated and cannulated screw).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 8, 2022. 
 
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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on March 8, 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 your doctors are recommending rehabilitation and 
the hospital cannot help you anymore. The Plan denied your request. The Plan says the IRF care is not 
medically necessary, and your needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. You continue to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that you would meet criteria for admission to an acute inpatient rehabilitation facility.  
 
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: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit provided by August 15, 2020. 
 
You asked the Plan to pay for an emergency department visit. The Plan denied your request. The Plan says that 
this claim is payable by traditional Medicare. 
 
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 us with proof of hospice enrollment. 
Therefore, we decided that the Plan has to pay for an emergency department visit provided by August 15, 2020.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid provided on March 16, 2022. 
 
You asked the Plan to pay for a hearing aid. You say that you could not find anyone in your area that would 
take this insurance. You finally found one 45 miles away, but you cannot drive anywhere near to that location.  
You also say you had to get your hearing aid where you could drive to. The Plan denied your request. The Plan 
says they have paid the maximum amount covered by your plan for this service. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for the 
hearing aid benefit and the hearing exam only when seen by the Plans partnering hearing benefit plan.  
 
 
  We looked at this physician's review, the file, and the Plan's rules. The record shows that the hearing aid was 
not purchased by the Plans partnering hearing benefit plan. Based on this information, we decided that the 
Plan's rules for coverage of a hearing aid have not been met. Therefore, we decided that the Plan does not have 
to pay for a hearing aid provided on March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (64483). 
 
You asked the Plan to pre-approve the repeat ESI. You say that the enrollee previously received more than a 
50% relief from the shot in May 2020. You say that the enrollee's pain has since flared. You also say that this 
should be approved as it was helpful in the past. The Plan denied your request. The Plan says the requested 
injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using same scale for at 
least three months. 
 
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 repeat ESI. Our reviewer says that 
the requested repeat ESI is not medically necessary.  
 
 Our physician reviewer found the documentation does not support that the patient has had at least 50% 
sustained improvement in pain relief and/or improvement in function measured from baseline for at least three 
months. Therefore, the reviewer found that a repeat ESI 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 repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (64483).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (11055, 11721, 99202) provided on 
August 27, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for FQHC claims with dates of service on or 
after January 1, 2010, FQHCs may report additional revenue codes when describing services rendered during 
an encounter. However, Medicare payment will continue to be reflected only on claim lines with the revenue 
codes listed. 
 
We looked at the file and Medicare rules. Revenue Code 0521 Clinic visit by member to RHC/FQHC was 
billed, however the records do not show that the provider is a Rural Health Clinic (RHC) or FQHC. Based on 
this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient services (11055, 11721, 99202) 
provided on August 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 13, 2021, 
to October 12, 2021. 
 
You asked the Plan to pay for the home health services. You say that this should be paid. The Plan denied your 
request. The Plan says no exception request was submitted to the Health Plan to waive the 5-day requirement 
for filing the RAP claim due to a circumstance beyond the provider's control. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, September 13, 2021. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from September 13, 2021, to October 12, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenetics testing provided on March 15, 2022. 
 
You asked the Plan to pay for the testing services. You say that medical records were provided. The Plan 
denied your request. The Plan says there is no documentation how the results will impact treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that pharmacogenetic testing is only covered under 
certain medical indications. 
 
We looked at the file and Medicare rules. The test at issue is not FDA approved. The records show that the 
testing brings guidance regarding medications and dosage. Medications should be provided based on the 
presence of a diagnosis and should be adjusted based on a patient's response to the medication. Genetic markers 
may or may not correlate with actual clinical findings. Furthermore, the gene panel was not billed with a single 
code as required. Based on this information, we decided that Medicare rules for coverage of the testing services 
have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenetics testing 
provided on March 15, 2022.