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

 
We decided that the Plan does not have to pay for procedure code 83036 billed for date of service April 7, 
2022. 
 
You asked the Plan to pay for procedure code 83036. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 83036 is bundled into payment for code 82985. 
 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 83036 
is a column II code to column I code 82985. 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 procedure code 83036 billed for date of service April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis, adjustable knee joints (unicentric or 
polycentric), positional orthosis, rigid support, prefabricated, off-the shelf (L1833). 
 
You asked the Plan to pre-approve a knee orthosis. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the requested knee orthosis was denied due to 
lack of medical necessity. 
 
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 knee 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 knee orthosis at issue 
in this case meets all Medicare criteria for medically reasonable and necessary for you. Provided records do not 
document a recent injury or a surgical procedure on the knee or knee instability documented by your 
examination showing objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior 
Drawer test) as required by the LCD. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid 
support, prefabricated, off-the shelf (L1833).
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 requested admission to an IRF does not meet 
criteria. 
 
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 enrollee was admitted for surgical repair of a femur fracture after a fall. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 5, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) colonography provided to the 
enrollee on May 20, 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 this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the 
record indicates that the enrollee underwent computed tomography (CT) colonography. The record provided is 
insufficient to determine whether the coverage criteria are satisfied.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for computed tomography (CT) colonography provided to the enrollee on May 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye appointment provided on June 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an eye appointment. You say that this should have been covered as it was 
medically necessary. The Plan denied your request. The Plan says there was no preauthorization by a primary 
care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was 
not an emergency. Therefore, the decision is upheld. 
 
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 eye appointment provided on June 23, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the denied service. The Plan 
denied your request. The Plan says the rendering provider is an OON provider and there was no referral from 
an in-network provider or an 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 May 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service June 17, 
2022. 
 You asked the Plan to pay for procedure code 71045. You say that you do not believe code 71045 is bundled 
with any other code. The Plan denied your request. The Plan says payment for code 71045 is bundled into 
payment for code 71046. 
 
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 71045 
is a column II code to column I code 71046. 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 procedure code 71045 billed for date of service June 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you thought an authorization was obtained so you 
treated the enrollee. The Plan denied your request. The Plan says the rendering provider is an OON provider 
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 July 13, 2022, by an 
out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on February 22, 2022. 
 
You asked the Plan to pay for the radiology services. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the patient was on hospice on the date of service 
in question. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for radiology services provided on February 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cystourethroscopy provided on April 26, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a cystourethroscopy. 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 a cystourethroscopy provided on April 26, 2022, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on May 5, 2022. 
 
You asked the Plan to pay for the x-ray services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
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 71045 is not supported in the medical record. Specifically, the documentation shows 
that this code was billed with place of service 22 (outpatient). The claim history shows that the enrollee was 
inpatient for this date of service. This means this claim is not payable as billed. Based on this information, we 
decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that 
the Plan does not have to pay for the x-ray services coded 71045 provided on May 5, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 27, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says Medicare only 
covers the visits if you get them from a health care provider who accepts assignment. It has been determined 
that the member had services rendered by a provider who is a licensed marriage and family therapist. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist (MFT) is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist 
(MFT). Medicare says that a Marriage Family Therapist (MFT) is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on 
April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided from May 23, 2022, to June 
6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that your plan does not need a referral for a 
doctor's visit. The Plan denied your request. The Plan says you were seen by an out-of-network provider. The 
Plan also says that the requested referral or authorization was not received in the allotted time frame. 
 
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 specialist office visit provided from May 23, 
2022, to June 6, 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 non-pneumatic compression controller with sequential 
calibrated gradient pressure (K1024) and a non-pneumatic sequential compression garment, full leg (K1032). 
 
You asked the Plan to pre-approve a non-pneumatic compression controller and compression garment. You say 
that the requested items are medically necessary for your plan of care. The Plan denied your request. The Plan 
says medical records reviewed show you have congenital lymphedema whose current treatments include 
compression therapies, manual lymphatic drainage, Flexi-touch pump and therapy sessions using primary 
lymphedema leg protocol and is demonstrating clinical improvements. Medicare does not cover treatments that 
are experimental or investigational due to unproven safety or efficacy, therefore the requested items are not 
approved. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
 
 
 
 
 
 
 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 non-pneumatic compression 
controller and compression garment. Our reviewer says that the service is not medically necessary. Our 
physician reviewer found based on the medical records provided there is no documentation that the non-
pneumatic compression controller with sequential calibrated gradient pressure (K1024) and a non-pneumatic 
sequential compression garment (K1032) at issue in this case meets all Medicare criteria for medically 
reasonable and necessary, safe, and effective for you, per Social Security Act, Section 1862 (a)(1)(A). There is 
no Local Coverage Determination or National Coverage Determination for non-pneumatic compression 
devices. Provided records do not document that the requested device meets Medicare criteria for coverage, that 
the device is standard of care for lymphedema, or the device has been shown to improve long term clinical 
outcomes in rigorous, controlled, randomized studies. 
 
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 non-pneumatic compression controller and compression garment have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a non-pneumatic compression 
controller with sequential calibrated gradient pressure (K1024) and a non-pneumatic sequential compression 
garment, full leg (K1032).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit, paring or cutting of benign hyperkeratotic 
lesion, and the trimming of nondystrophic nails provided on July 12, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for a home visit, paring or cutting of benign hyperkeratotic lesion, and the trimming 
of nondystrophic nails. You say that you did inform the front desk secretary to obtain prior authorization. You 
also say that the patient was called in for treatment, prior to obtaining authorization. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan. The Plan also says that 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 home visit, paring or cutting of benign 
hyperkeratotic lesion, and the trimming of nondystrophic nails provided on July 12, 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 copayment for an office visit provided on July 9, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you went to this facility for a 
sprained ankle. 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 $10 
copayment for primary care provider visit for Medicare covered services.  
 
You have been asked to pay a $10 copayment for an office visit. This item/service falls within the primary care 
provider visit for Medicare covered 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 an office visit provided on July 9, 2022.  
 Your complaint about the potentially poor service in handling the COVID-19 exposure 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.