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

 
We decided that the Plan does not have to pay for paring or cutting of benign hyperkeratotic lesion (e.g., corn 
or callus); single lesion provided on July 19, 2022. 
 You asked the Plan to pay for paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single 
lesion. You say that the services were medically necessary. The Plan denied your request. The Plan says paring 
or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion is excluded from Medicare 
coverage guidelines. 
 
The Plan follows Medicare rules. Medicare rules say that the Medicare program generally excludes routine foot 
care services from coverage, there are specific indications or exceptions under which there are program 
benefits. 
 
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 paring or cutting of benign hyperkeratotic 
lesion (e.g., corn or callus); single lesion. Our reviewer says that paring or cutting of benign hyperkeratotic 
lesion (e.g., corn or callus); single lesion is not medically necessary. Our physician reviewer found that it is 
well established in the medical documentation that you are suffering with a painful lesion to the plantar aspect 
of the left foot. The lesion has been debrided. Medicare advises that Medicare payment may be made for 
routine foot care when the patient has a systemic disease, such as a metabolic, neurologic, or peripheral 
vascular disease, of sufficient severity that performance of such services by a nonprofessional person would put 
the patient at risk (for example, a systemic condition that has resulted in severe circulatory embarrassment or 
areas of desensitization in the patient's legs or feet). The medical documentation does not support that you have 
severe peripheral vascular disease, or a metabolic or neurologic condition that would put your foot or leg at risk 
if the lesion was not removed by a professional. Therefore, the pairing/cutting of a benign hyperkeratotic lesion 
does not meet Medicare coverage guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single 
lesion have not been met. Therefore, we decided that the Plan does not have to pay for paring or cutting of 
benign hyperkeratotic lesion (e.g., corn or callus); single lesion provided on July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed service provided on March 
29, 2022. 
 
You asked the Plan to waive the copayment for urgently needed service. You say that you were informed by 
the front desk that you didn't have to pay any copayment for this visit. 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 $25 
copayment for Medicare-covered urgently needed care visit.  
 
You have been asked to pay $25 copayment for urgently needed service. This item/service falls within the 
Medicare-covered urgently needed care visit 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 urgently needed service provided on March 29, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for the requested drug have not been 
met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Orthovisc or Supartz FX before they will approve the requested drug, Euflexxa. In 
this case, the enrollee has not tried and failed the required drugs. There is no documentation provided 
indicating that the Plans required drugs likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Euflexxa (J7323).
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. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for approval. 
 
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 the documentation does not support the medical necessity for admission to an IRF 
due to lack of medical complexity and lack of nursing needs. Our reviewer also found that while the enrollee 
would benefit from physical therapy and occupational therapy, their rehabilitation needs can be safely provided 
in an alternate and low intensity setting, such as in a skilled nursing 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit provided on August 6, 2021, by an 
OON provider. 
 
You asked the Plan to pay for an emergency room visit. 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 emergency room visit provided on August 6, 
2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left-knee arthroscopy (29881). 
 
You asked the Plan to pre-approve a left-knee arthroscopy. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 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 a left-knee arthroscopy. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that detailed documentation is not evident regarding trial and failure of recent, 
reasonable and comprehensive, less invasive conservative-care measures. There are limited large-scale, long-
term references showing the safety and efficacy of the requested surgery in the enrollee's clinical setting. There 
is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 left-knee arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a left-knee arthroscopy (29881).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee was referred to you and the service 
provided was medically necessary. The Plan denied your request. The Plan says the rendering and referring 
providers are both OON providers and there was no approved authorization. Also, the service rendered was not 
urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on June 21, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient psychiatric services rendered on March 16, 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that psychiatric hospitals must be billed with taxonomy 
code 283Q00000X. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 
taxonomy code. 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 inpatient psychiatric services 
rendered on March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and chiropractic service provided on June 17, 
2021 to June 22, 2021, by an OON provider. 
 
You asked the Plan to pay for an office visit and chiropractic service. You say that you feel this is a legal claim 
and should be paid. 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 and chiropractic service provided on 
June 17, 2021 to June 22, 2021, by OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 23, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you should not pay the 
copayment because you do not remember the ride on the ambulance. 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 a $270 
copayment for ambulance services.  
 
You have been asked to pay a $270 copayment for ambulance services. This item/service falls within the 
Ambulance services 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 ambulance services 
provided on May 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heating pad rendered on April 6, 2022, 
to April 28, 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 a water circulating heat pad with pump (E0217) 
is denied as not medically necessary. 
 
We looked at the file and Medicare rules. The services at issue are a water circulating head pad with pump 
billed with code E0217. This item is not covered by Medicare. Therefore, we decided that the Plan does not 
have to pay for the water circulating heating pad rendered on April 6, 2022, to April 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the outpatient hospital services provided 
on January 13, 2022, to February 11, 2022. 
 
You asked the Plan to reduce the copayment for the outpatient hospital services. You say that these should be 
billed as office visits. 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 a $590 
copayment for outpatient hospital services. 
 
You have been asked to pay a $590 copayment for the outpatient hospital services. This item/service falls 
within the outpatient hospital services 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. Per the EOC, there is a $295 copayment for outpatient hospital services. The 
total for both visits is $590. Therefore, we decided that the Plan does not have to reduce the copayment for the 
outpatient hospital services provided on January 13, 2022, to February 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on May 25, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for x-rays. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says care that the enrollee receives from out-of-network providers will not be covered unless 
the care meets one of the three exceptions described in Section 1.2 of this chapter. 
 
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 x-rays provided on May 25, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth visit provided on May 06, 
2022. 
 
You asked the Plan to waive the copayment for a telehealth visit. You say that no one advised you that a 
telehealth is considered a specialist visit 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 a $30 
copayment for specialist visit in office or telehealth. 
 
You have been asked to pay a $30 copayment for a telehealth visit. This item/service falls within the specialist 
visit in office or telehealth benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for a telehealth 
visit provided on May 06, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 23, 2022, billed with 
codes 81162, 81201, 81208, 81218, 81292, 81295, 81298, 81307, 81314, 81321, 81334, 81351, 81406, and 
81437. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services should be billed with a single panel code. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 23, 2022, billed with codes 81162, 81201, 81208, 81218, 81292, 81295, 81298, 81307, 81314, 81321, 
81334, 81351, 81406, and 81437.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the surgery services. You say that it is medically necessary for you to get 
the surgery done. The Plan denied your request. The Plan says the requested provider is an OON provider and 
there are multiple in-network providers which have been approved that can provide the same type of service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
cataract surgery to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 11, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

  
We decided that the Plan does not have to pre-approve custom foot orthotics (L3020) and orthopedic footwear, 
ladies shoes (L3215). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthopedic footwear) are only covered for 
patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthopedic footwear may be appropriate for you, neither Medicare nor the Plan provides coverage of 
orthopedic footwear for your condition. Additionally, Medicare rules say that with the exception of the 
situations described above, orthopedic footwear billed using codes L3020 and L3215 will be denied as 
noncovered. Therefore, we decided that the Plan does not have to pre-approve custom foot orthotics (L3020) 
and orthopedic footwear, ladies shoes (L3215).