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

 
We decided that the Plan does not have to pay for the chiropractic visits provided on February 18, 2022, to 
February 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic visits. You say that you were not aware the provider did not 
accept Medicare. You say you are looking for reimbursement. The Plan denied your request. The Plan says no 
prior authorization was 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 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 chiropractic visits provided on February 18, 
2022, to February 21, 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 group 3 power wheelchair, multiple power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds electronic connection (E2311) 
expandable controller (E2377) and expandable controller harness (E2313) and seat elevator (E2300). 
 
You asked the Plan to pre-approve the power wheelchair. You say that the enrollee is experiencing chronic 
back pain a frequent falls. The enrollee needs the power wheelchair to ease mobility. The Plan denied your 
request. The Plan says the enrollee does not have a medical need for multiple power options included with a 
group 3 power wheelchair and the request is not reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not reveal that the enrollee uses a ventilator attached to a 
wheelchair, is at high risk for development of a pressure ulcer. There is no evidence of intermittent 
catheterization. The physician documentation does not indicate objective evidence of spasticity on a BLE 
physical exam that needs a power seating system for management therefore the request for power tilt and 
recline exceeds the patient's medical needs.  The enrollee also does not have a Group 3 qualifying diagnosis of 
a mobility limitation that is due to a neurological condition, a myopathy, or a congenital skeletal deformity. 
The request for a Group 3 power wheelchair with multiple accessories exceed the patient's medical need. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve group 3 power wheelchair, multiple power option, sling/solid seat/back, patient 
weight capacity up to and including 300 pounds electronic connection (E2311) expandable controller (E2377) 
and expandable controller harness (E2313) and seat elevator (E2300).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of a lower extremity 
(73700) provided on March 4, 2022. 
 
You asked the Plan to pre-approve a CT scan. You say that this service is necessary and should be covered. 
The Plan denied your request. The Plan says the criteria for a CT scan are not met in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan. Our reviewer says that the 
requested imaging service is not medically necessary. Our physician reviewer found that there are no exams 
providing any subjective and/or objective findings to support this request. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested computed tomography (CT) of the lower extremity (CPT 73700), 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 a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) of a lower extremity (73700) provided on March 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequence (NGS) testing panel provided 
on December 13, 2021. 
 
You asked the Plan to pay for the NGS testing panel. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the NGS testing provided included 
testing for the FANCC gene. This means the entire panel is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the NGS testing panel have not been met. Therefore, we decided 
that the Plan does not have to pay for the next generation sequence (NGS) testing panel provided on December 
13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving the care he needs in the hospital 
where he is now and there is no need to transfer to the LTACH at this time. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. All medically necessary care is being provided in the current acute care setting. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on October 16, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this testing is statutorily non-covered 
by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing services provided 
on October 16, 2021, have been met. In this case, no clinical records have been received from the enrollees ordering provider to indicate the 
medical necessity of the ordered testing. Therefore, we decided that the Plan does not have to pay for the 
genetic testing services provided on October 16, 2021.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided 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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for cervical spine 
surgery. The enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. The 
patient does 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 this 
patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a positron emission tomography (PET) scan. 
 
You asked the Plan to pay for a positron emission tomography (PET) scan. You say that the service is 
medically necessary. The Plan denied your request. The Plan says that the requested study would exceed the 
allowed limit of three scans. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 pay for a positron emission tomography (PET) scan. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found Increased tumor 
marker levels detected in asymptomatic breast cancer patients during adjuvant therapies and follow-up are 
significantly predictive of distant metastases identified on FDG-PET/CT. Exploratory findings suggest that 
FDG-PET/CT has greater accuracy than conventional imaging in patients with suspected recurrent breast 
cancer. The service was reasonable and 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 a positron emission tomography (PET) scan have been met. Therefore, we 
decided that the Plan has to pay for a positron emission tomography (PET) scan.  
 
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 lab services (G0480, 80307) provided January 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service was already paid for this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that one Presumptive drug testing code may be billed 
once per patient per day. 
 
We looked at the file and Medicare rules. This service was already approved and paid for this date of service. 
Only one drug testing code may be billed per patient, per day. 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 lab services (G0480, 80307) provided January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for radiation therapy treatments provided 
from September 9, 2021, to October 11, 2021. 
 
You asked the Plan to waive the copayments for the radiation therapy. You say that you would not have the 
service if you knew you would have to pay. 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 $10 
copayment for each therapeutic radiology service.  
 
The file shows that you had a total of 12 visits for radiation therapy from September 9, 2021, to October 11, 
2021. Therefore, you have been asked to pay a $10 copayment for each visit for the radiation therapy, for a 
total of $120 ($10 copayment x 12 visits = $120). The radiation therapy 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 copayments for radiation therapy treatments 
provided from September 9, 2021, to October 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for intravenous infusion on February 01, 
2022. 
 
You asked the Plan to waive the coinsurance for intravenous infusion. You say that you were under the 
impression this would be covered at 100%. The Plan denied your request. The Plan says the cost-sharing you 
are being charged is correct. 
 
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 Medicare Part B drugs. Part B drugs obtained in a provider's office or outpatient setting. The 
provider billed in the amount of $1,092 and the allowed amount is $429.69. Therefore, resulting in the total 
cost-sharing amount of $85.94.  
 
 
 
  
You have been asked to pay a 20% coinsurance for intravenous infusion. Intravenous infusions fall within the 
Medicare Part B prescription drugs 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 
intravenous infusion on February 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 18, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that the documents submitted to the Plan were illegible, incomplete, and failed to 
include why the provider ordered these specific tests. Without this documentation, this means that the 
laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on August 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for office visit on February 28, 2022. 
 
You asked the Plan to waive the coinsurance for office visit. You say that you were told by a representative that 
the claim was not paid because the provider is out-of-network. You want the claim to be reimbursed and fixed 
in the future and feel the plan should have more coverage for the services. The Plan denied your request. The 
Plan says the cost-sharing you are being charged is correct. 
 
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 45% 
coinsurance for out-of-network office visit for members eligible for this Medicare-covered service. The 
provider billed in the amount of $2,474.32 and the allowed amount is $919.68. Therefore, resulting in the total 
cost-sharing amount of $413.85. 
 
 
  
You have been asked to pay a 45% coinsurance for office visit. Office visits fall within the 
Physician/Practitioner services, including doctor's 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 coinsurance for office visit on February 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic breast tomosynthesis (77061) provided on 
January 13, 2022. 
 
You asked the Plan to pay for a diagnostic breast tomosynthesis. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
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 77061 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 77061 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of a diagnostic breast tomosynthesis have not been met. Therefore, we decided that the Plan does not 
have to pay for a diagnostic breast tomosynthesis (77061) provided on January 13, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve consultation and treatment with out-of-network providers. 
 
You asked the Plan to pre-approve consultation and treatment. You say that none of the in-network doctors 
have been able to treat you and you need to be fixed properly. The Plan denied your request. The Plan says that 
the denial of authorization for these services is correct, because the requested providers are out-of-network with 
the Plan and you can be treated by an in-network provider. 
 
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. Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are 
plan providers available to meet enrollees needs. 
 
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 did not submit a copy of the applicable Evidence of Coverage (EOC) 
or other Plan contract document. Without this document, we cannot determine whether there is a network lock-
in rule that would apply to your request. Therefore, the Plan has not shown that its decision to deny coverage 
for the requested out-of-network providers is correct or justified according to Medicare rules and your contract with the Plan. Therefore, we decided that the Plan has to pre-approve consultation and treatment with out-of-
network providers.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adhesive bandage coded A6413 provided on January 16, 
2022. 
 
You asked the Plan to pay for the adhesive bandage. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the item billed is not a covered benefit. 
 
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 A6413 is adhesive bandage, first-aid type, any size, each. 
 
 
 
 We find that CPT code A6413 is not supported in the medical record. Specifically, this code has a status code 
of "N", which means this code is specifically non-covered. Based on this information, we decided that 
Medicare rules for coverage of the adhesive bandage have not been met. Therefore, we decided that the Plan 
does not have to pay for the adhesive bandage coded A6413 provided on January 16, 2022.