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

 
We decided that the Plan does not have to pay for a pathology and laboratory service provided on March 15, 
2022, by an OON provider. 
 
You asked the Plan to pay for a pathology and laboratory service. You say that the test was denied in error and 
we are requesting it be reprocessed in accordance of the Medicare Managed Care manual guidelines. 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 pathology and laboratory service provided on 
March 15, 2022, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81235, 81321) provided June 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were 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 a panel constitutes a single procedural service, so 
one procedure code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. 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 (81206, 81235, 81321) provided June 
26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile gloves rendered on March 6, 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 covered. 
 
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 A4930 has a status indicator of X on the Physician Fee Schedule. This means that CPT 
code A4930 is not payable. 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 sterile gloves 
rendered on March 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bilateral ankle orthosis provided on February 18, 2022. 
 
You asked the Plan to pay for the ankle orthosis. You say that this would have been covered by Original 
Medicare. The Plan denied your request. The Plan says there are no records showing that this item is medically 
necessary. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is only covered if the medical 
documentation supports coverage. If the information in the patients medical record does not adequately 
support the medical necessity for the item, the supplier is liable 
 
 
 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, there is no mention in the medical records supplied of any condition for which the 
ankle orthosis may have been ordered. The only diagnoses listed in the medical records do not relate to the 
ankle in any way.  There is nothing in the medical records explaining why the physician may have ordered this 
item for this patient. Therefore, we decided that the Plan does not have to pay for the bilateral ankle orthosis 
provided on February 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided on March 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that you were never advised that this would not 
be covered and you do not think it's right that you are responsible for this. The Plan denied your request. The 
Plan says unauthorized, non-plan 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. 
 
Both the lab that performed the pathology services and the dermatologist who took the sample are non-contract 
providers with the Plan.  You self-referred to this non-contract provider and did not have prior authorization 
from the Plan for these services. 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 pathology services provided on 
March 1, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for health club membership services for the 2020 calendar year. 
 
You asked the Plan to pay for health club services in 2020.. You say that you received reimbursement for the 
2021 plan year, but you have not received reimbursement on this claim for 2020 yet. The Plan denied your 
request. The Plan says you have already used your full 2020 fitness allowance. A check for $300 
reimbursement was provided to you on May 8, 2020. You are responsible for the remaining costs, as your full 
allowance has already been used. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only up to $300 per calendar year. You are responsible for all charges over $300 per year. Reimbursement 
requests must be received by the Plan no later than March 31 of the following year. 
 
The Plans rules for coverage of gym benefits have not been met because the record shows that you have 
already received the full allowance for health and wellness services in 2020. Therefore, we decided that the 
Plan does not have to pay for health club membership services for the 2020 calendar year.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Removal of implant (20680) provided on March 31, 
2021. 
 
You asked the Plan to pay for code 20680. You say that the medical records support the billing of code 20680 
provided on March 31, 2021. The Plan denied your request. The Plan says the medical records do not support 
the billing of code 20680 provided on March 31, 2021. 
 
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 20680 is Removal of implant; deep (eg, buried wire, pin, 
screw, metal band, nail, rod or plate). 
 
 
 
 
 
 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 code 20680. Our reviewer says that the medical records do 
not support the billing of code 20680 provided on March 31, 2021. Our reviewer found the operative report 
documents:  "We started to mobilize the mesh by separating it anteriorly from the abdominal wall and 
posteriorly from the abdominal contents.  We were able to free most of it bluntly but there was significant 
amount of adhesions in the abdomen that needed to be taken sharply with metz and a scapel". Operative report 
describes mesh removal. In this case, there is a more appropriate code to report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 20680 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Removal of implant (20680) provided on March 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an x-ray provided on March 3, 2022. 
 
You asked the Plan to waive the deductible for an x-ray. You say that the plan should cover the costs. The Plan 
denied your request. The Plan says the deductible applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $290 deductible which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $290 deductible which applies to x-rays. This cost sharing is a 
contractual obligation that had not been met at the time an x-ray was received on March 3, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible for an x-ray provided on March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on December 2, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says genetic testing 
submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of 
the patient. 
 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. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services provided on December 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Embrace 2 seizure monitor. 
 
You asked the Plan to pre-approve Embrace 2 seizure monitor. You say that you need this item to find an 
explanation for the seizures you are having. The Plan denied your request. The Plan says the requested item is 
not medically necessary. 
 
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 Embrace 2 seizure monitor. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have a diagnosis of seizure disorder. It is documented that your last 
seizure was in December 2021. The available documentation in the case file does not support that an Embrace 
2 seizure monitor is medically reasonable and necessary in this case. The documentation does not support that 
the requested device is needed to diagnose or treat you. Therefore, you do not meet criteria for the requested 
device. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Embrace 2 seizure monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Embrace 2 seizure monitor.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
services are medically necessary. Our physician reviewer found based on the medical records provided there is 
documentation that you require the services on an inpatient basis in a skilled nursing facility setting. Records 
document a significant decline in your functional status compared to your baseline to require therapy services 
on an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for imaging services provided on March 7, 
2022. 
 
You asked the Plan to waive the copayment for imaging services. You say that the copayment is getting to be 
too much, and you are on a fixed income. The Plan denied your request. The Plan says the copayment applied 
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 $325 
copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds.  
 
 
 
 You have been asked to pay $325 copayment for imaging services. Imaging services 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 imaging services provided on March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2331, 
E1028, E2300, K0108x2) 
 
You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The 
Plan denied your request. The Plan says mounting hardware for the Omni Joystick cannot be covered, as the 
attendant control cannot be covered. 
 
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 additional accessories. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the power seat elevation feature is statutorily non-covered as it serves no primary 
medical purpose. The attendant control is not covered in addition to a patient-operated controller. Mounting 
hardware for the Omni Joystick is not covered as the attendant control is not covered. The arm pads are denied 
as unbundled charges. 
 
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 additional accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional power wheelchair accessories (E2331, E1028, E2300, K0108x2)
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional x-ray services provided to the enrollee on 
February 24, 2022. 
 
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 a review of the medical records submitted indicates that one chest x-ray was performed or 
supported. 
 
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 71045 is "Radiologic examination, chest; single view." 
 
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 that a single exam, one view chest x-
ray was done on 2/24/22, and signed by the doctor at 11:21. 
 
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 additional x-ray services provided to the enrollee on February 24, 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 enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee has chronic 
functional loss with recent exacerbation. She has no acute neurological or limb impairment. She has 
generalized weakness and chronic deconditioning. She does not have intensive or complex rehabilitation needs 
requiring frequent physiatry oversight. She has chronic rehabilitation needs consistent with chronic disease. 
Her rehabilitation needs are consistent with standard post-acute rehabilitation needs which do not require 
admission to an acute care rehab 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 22, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that no authorization was required. 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 an office visit provided on March 22, 2022, by an 
OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on March 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for hospital services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained for these services. 
 
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 hospital services provided on March 22, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960) provided 
January 28, 2022. 
 
You asked the Plan to pay for the orthosis. You say that this claim met all of Medicare's DME LCD coverage 
criteria. The Plan denied your request. The Plan says the records do not adequately support the medical 
necessity for the item. 
 
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 pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that the shoulder, elbow, 
wrist, hand orthosis at issue in this case meets Medicare criteria for medically reasonable and necessary. The only face to face visit note provided to this reviewer was from a visit on 10/25/2021 and no mention of a 
shoulder problem or need for an orthosis was documented in this note. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the shoulder elbow wrist hand orthosis (L3960) provided January 28, 2022.