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

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 27, 
2021. 
 
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 an appropriate modifier was not billed in this case. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 74018 
is a column II code to column I code 74019. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99202) provided on November 3, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the provider deemed it necessary to perform these 
tests/procedures based on their findings during the examination. The Plan denied your request. The Plan says 
this provider is not a network provider with the Plan and the services were not referred by a network provider 
or rendered in an in-network facility. The Plan also says that they have also determined that these services are 
not urgent or emergent, nor were they approved in advance. 
 
 
 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 (99202) provided on November 3, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for an urgent care visit provided on October 
28, 2021. 
 
You asked the Plan to waive the cost-sharing for the urgent care visit. You say that the services should be 
covered as you disagree with the charge. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided, you were charged a copayment for the visit; not the COVID-19 test. 
 
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 Urgently needed services.  
 
 
  You have been asked to pay a $30 copayment for an urgent care visit. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
cost-sharing for an urgent care visit provided on October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro 2 represents this enrollee's best 
opportunity for regaining meaningful use for his right upper limb and has been deemed medically necessary for 
this enrollee by his provider. The Plan denied your request. The Plan says this item is considered experimental 
and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 21, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the ordering physician requested this test 
you could not obtain an authorization. The Plan denied your request. The Plan says the rendering and referring 
providers are both out-of-network 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 the laboratory services provided on September 21, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Skin Substitute Grafts provided on March 23, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Skin Substitute Grafts. You say that you would like to appeal the claim payment 
denial for services rendered. The Plan denied your request. The Plan says the care wasn't approved in 
compliance with the health plan's authorization procedures. 
 
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 Skin Substitute Grafts 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 Skin Substitute Grafts these 
items/services. Therefore, we decided that the Plan does not have to pay for Skin Substitute Grafts provided on 
March 23, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a gadobutrol injection (contrast agent) 
provided on November 16, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that your plan does not have 
coinsurance amounts for radiology tests. The Plan denied your request. The Plan says the correct coinsurance 
was 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 20% 
coinsurance for medical supplies, including chemical agents used in certain diagnostic procedures.  
 
You have been asked to pay $10.60, which is 20% of the allowed amount for the injection ($53.00 allowed amount x 20% coinsurance = $10.60). The injection 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 coinsurance for a 
gadobutrol injection (contrast agent) provided on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 8, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that you are in the Plan's network. The Plan denied your 
request. The Plan says you are not in their network. 
 
  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 the office visit provided on September 8, 2021, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Subsequent Nursing Facility Care provided on November 15, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient Mental Health. You say that the member has a history of anxiety 
disorder, mood affective disorder, and sleep disorder. The Plan denied your request. The Plan says there is no 
evidence of an emergency or urgent situation that would require the use of out-of-network 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 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. The record shows that this visit was not provided on an emergency basis. We found no 
exception that would require the Plan to pay for Subsequent Nursing Facility Care these items/services. 
Therefore, we decided that the Plan does not have to pay for Subsequent Nursing Facility Care provided on 
November 15, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve SI joint injection. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because SI 
joint injections are not supported when clinical findings suggest other obvious sources of pain. 
 
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 SI joint injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are other causes of pain present (such as degenerative lumbar spinal stenosis 
and lumbar spondylosis). The clinical value and effectiveness of an SI joint injection in the absence of 
tenderness and negative provocative testing results have not been demonstrated in peer-reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tempus Gene Panel provided on August 9, 2021. 
 
You asked the Plan to pay for the Tempus Gene Panel. You say that the Tempus Gene Panel provided on 
August 9, 2021, was medically necessary. The Plan denied your request. The Plan says that the Tempus Gene 
Panel provided on August 9, 2021, was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Tempus Gene Panel. Our reviewer says 
that the Tempus Gene Panel provided on August 9, 2021, was medically necessary. Our physician reviewer 
found adenocarcinoma of the esophagus that has metastasized carries a poor prognosis. Next Generation 
Sequencing (NGS) offers the opportunity to assess numerous mutations simultaneously, along with other 
molecular events such as amplification, deletions, tumor mutation burden, and MSI status. This enrollee is 
HER2 negative and NGS is recommended by the NCCN Guidelines. NGS with Tempus 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 the Tempus Gene Panel have been met. Therefore, we decided that the Plan has 
to pay for the Tempus Gene Panel provided on August 9, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device (K0823, E1028). 
 
You asked the Plan to pre-approve the power mobility device. You say that the power wheelchair is medically 
necessary. The Plan denied your request. The Plan says this device is primarily for use in the community and is 
not required for use in the home by the enrollee. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power mobility device (K0823, E1028).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 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 skilled nursing facility 
(SNF) care. have been met. Medical records were not provided to verify if the admission is necessary. 
Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an En Block Capsulectomy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an You say that The enrollee is experiencing chronic pain and the services 
are necessary. The Plan denied your request. The Plan says The denial of authorization for these services is 
correct. 
 
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 an en block capsulectomy 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 an En Block Capsulectomy these items/services. Therefore, we decided that the Plan 
does not have to pre-approve an En Block Capsulectomy to be provided by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services with a provider not enrolled in Medicare. 
 
You asked the Plan to pre-approve dental services with a provider not enrolled in Medicare. You say that you 
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested dental 
provider has not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve dental services with a provider not 
enrolled in Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit (99214) rendered on October 
27, 2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that the first time you went, you asked 
if there was a copayment, and nobody said anything. The Plan denied your request. The Plan says you were 
charged the correct copayment. 
 
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 $40 
copayment for Medicare-covered specialist visit.  
 
You have been asked to pay a $40 copayment for an office visit. an office visit falls within the Medicare-
covered specialist 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 an office 
visit (99214) rendered on October 27, 2021.   
Your complaint about potentially being billed for services you have already paid is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are 
no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
  
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (62322) provided on October 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 62322 
is a column II code to column I code 00790. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for the services (62322) provided on 
October 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the services at issue are medically 
necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric care. Our reviewer 
says that the enrollee does not meet the criteria for acute inpatient mental health treatment. Our physician 
reviewer found the enrollee did not require inpatient mental health treatment as he was not a danger to himself 
or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place. It did not appear that the services were reasonably expected or medically necessary 
to improve the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.