Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on October 4, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the benefit limit for D0140 has already been met and exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers one limited 
oral evaluation per calendar year. 
 
 
 
 
 
 We looked at the file and Medicare rules. Evidence was provided to show that D0140 was previously provided 
on July 12, 2021. Based on this information, we decided that the Plan's rules for coverage of a limited oral 
evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140) provided by a participating provider on October 4, 2021. This appeal only addresses D0140
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on November 21, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
 
 
 
 We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing services provided on November 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 23, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the assisted living facility is 
responsible to obtain prior authorization for all of their patients, which should also cover for the medical 
treatments provided by this provider. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan, and authorization was not obtained prior to the services being rendered. 
 
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 domiciliary or rest home visit provided on 
November 23, 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 wheeled folding walker (E0143) and a walker seat 
attachment (E0156) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a folding walker and a walker seat attachment. You say that you are 
requesting reconsideration for the denial of your rolling walker with seat attachment. The Plan denied your 
request. The Plan says you must use network providers to get health care and services when there are network 
providers available. 
 
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 a wheeled folding walker (E0143) and a 
walker seat attachment (E0156) to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
November 9, 2021 to November 30, 2021. 
 
You asked the Plan to pay for home health services. You say that you have always followed the guidelines as 
communicated by the Plan. Please reconsider as the Plan guidelines have always been met. The Plan denied 
your request. The Plan says the Plan did not receive the initial request for anticipated payments (RAP) claim 
within 5 calendar days from the start of care. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the provider 
did not submit a RAP calm for the home health care period which started on November 9, 2021 and ended on 
November 30, 2021. Therefore, we decided that the Plan does not have to pay for the home health services 
provided to the enrollee from November 9, 2021 to November 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for enteral formula purchased from an online retail provider.   
 
You asked the Plan to pay for enteral formula purchased from an online retail provider. You say that this 
product was medically necessary and recommended by your physician. The Plan denied your request. The Plan 
says this provider does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except. 
This product was purchased from a retail commercial provider who does not participate with Medicare.  
Therefore, we decided that the Plan does not have to pay for enteral formula purchased from December 13, 
2021, to December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar epidural injections (64483). 
 
You asked the Plan to pre-approve the injections. You say that you are requesting an appeal for the denial of 
epidural steroid injections based on medical necessity. The Plan denied your request. The Plan says there is no 
clinical information documenting medical necessity or that meets Medicare medical necessity criteria. 
 
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 injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the LCD criteria states: repeat ESI when the first injection directly and significantly provided 
improvement of the condition being treated may be considered medically reasonable and necessary when the 
medical record documents at least 50% of sustained improvement in pain relief and/or improvement in function 
measured from baseline using the same scale for at least three months. This request does not meet these criteria 
and is therefore, not medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar epidural injections (64483).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care with an approved 
elective reverse total shoulder arthroplasty. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee requires an inpatient 
stay. The Plan denied your request. The Plan says there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is undergoing planned, elective left shoulder surgery. She 
is medically stable. The planned procedure, listed under code 23472, is not listed on the CMS Inpatient Only 
List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to 
support the expectation the enrollee will require a greater than 2 midnight stay. The review has determined that 
the record does not show that at the time of admission the admitting physician would reasonably expect that the 
enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care with an approved elective reverse total 
shoulder arthroplasty.
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 records do not show that the enrollee needs care that can only 
be given in a hospital or that the enrollee's condition will require an average 25 day length of stay at an 
LTACH. 
 
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 patient 
appears to be more stable and improving and should only require short-term additional acute care services that 
can safely be completed at the current facility until more appropriate for a lower level of care. The patient does 
not require services at the LTACH that are not already available at the current facility. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) with a gastroenterologist for a 
second opinion to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you have esophageal cancer, and the 
chemotherapy is not working. Your provider advised you need another option of chemotherapy. You are 
requesting assistance from the Plan. The Plan denied your request. The Plan says they have a tertiary provider 
available that can provide the services at issue in this request. The Plan also says that the Plan arranges 
specialty care outside of the plan provider network when network providers are unavailable or inadequate to 
meet the enrollee's needs. 
 
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 
an office visit (99204) with a gastroenterologist for a second opinion to be provided by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99309) provided on February 15, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was 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 nursing facility care (99309) provided on February 
15, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided the Plan does not have to pay for physician services provided to the enrollee on September 24, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim was not timely filed. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. The record shows that a claim for this 
service was not filed until January 4, 2022. This means that more than one calendar year from the date of 
service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee on September 24, 2020.
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's medical needs are being met in the current acute 
setting. 
 
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 patient 
appears to be more stable and improving and should only require short-term additional acute care services that 
can safely be completed at the current facility until more appropriate for a lower level of care. The patient does 
not require services at the LTACH that are not already available at the current facility. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intermittent limb compression device (CPT code 
E0676). 
 
You asked the Plan to pre-approve the intermittent limb compression device. You say that this device would 
keep blood circulating in your legs and will allow for you to have a faster recovery after the hip surgery. The 
Plan denied your request. The Plan says items that are used for a preventative service or function are excluded 
from coverage under the Medicare durable medical equipment (DME) benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. We looked at the file 
and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have 
not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for 
preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they 
are billed on the claim. Therefore, we decided that the Plan does not have to pre-approve the intermittent limb 
compression device (CPT code E0676).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-rays (73562 x 2) and myocardial perfusion imaging, 
tomographic (SPECT) (78452) provided on January 23, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic imaging services. You say that you rely on hospital personnel to 
obtain all necessary paperwork including authorization numbers and referral forms. The Plan denied your 
request. The Plan says the claim processed correctly. 
 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 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 x-rays (73562 x 2) and myocardial perfusion imaging, 
tomographic (SPECT) (78452) provided on January 23, 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 a replacement prosthetic foot. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a prosthetic foot is covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found Medicare allows for replacement of a 
prosthesis or prosthetic component if there is a change in the physiological condition of the beneficiary, there is 
irreparable wear of the device or a part of the device or if the condition of the device, or part of the device, 
requires repairs and the cost of such repairs would be more than 60% of the cost of a replacement device, or the 
part being replaced. The documentation does not support that you require a replacement prosthesis with a K2 
level of function. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a replacement prosthetic foot.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on January 20, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this service should be covered. 
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 $350 
copayment per visit at a hospital outpatient facility. 
 
You have been asked to pay $186.38 which is less than the standard $350 copayment for outpatient surgery. 
Outpatient surgery falls within the Outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers 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 outpatient surgery provided on January 20, 2022.