Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a high strength lightweight wheelchair (K0004) provided on 
February 7, 2022. 
 
You asked the Plan to pay for a high strength lightweight wheelchair. You say that the Plan provides coverage 
of durable medical equipment without prior authorization for the item at issue. The Plan denied your request. 
The Plan says rules for payment have not been met because the claim at issue is a duplicate of another claim 
that has been processed and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a high strength lightweight wheelchair have not been met. Specifically, the Plan has documented 
that the claim at issue is a duplicate of another claim that has been processed and paid. Therefore, we decided that the Plan does not have to pay for a high strength lightweight wheelchair (K0004) provided on February 7, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) of the brain provided 
on January 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an MRI of the brain. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the member's plan excludes coverage for this out-of-network 
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 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 magnetic resonance imaging (MRI) of the brain 
provided on January 25, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray provided on February 4, 2022. 
 
You asked the Plan to pay for a chest x-ray. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the member's Plan excludes coverage for this out-of-network 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 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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a chest x-ray provided on February 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) test (0037U) provided 
January 22, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx meets the 
requirements of the NCD and has been determined by CMS to be reasonable and necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet Medicare 
NCD/LCD criteria. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for FoundationOne CDx (F1CDx) test (0037U) provided January 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on January 21, 2022, to 
January 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says they were 
unable to make a determination within 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 the physician services provided on January 21, 
2022, to January 28, 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 computed tomography (CT) scan of the head/brain 
rendered on January 11, 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 separately payable.  
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 70450 
is a column II code to column I code 70496. 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 the computed tomography (CT) scan of the head/brain rendered 
on January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intermittent urinary catheter (A4353) provided on May 7, 
2021. 
 
You asked the Plan to pay for an intermittent urinary catheter. You say that the requested item was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the patients medical record adequately supports the medical necessity for the item.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for an intermittent urinary catheter 
(A4353) provided on May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for facial electrolysis treatments provided on January 4, 2021, to 
November 29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the facial electrolysis treatment. You say that the electrolysis was determined to 
be necessary, and therefore, should be covered. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
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 did not pre-approve the 
facial electrolysis treatments. We found no exception that would require the Plan to pay for the facial 
electrolysis treatments. The records provided for review do not show that the services at issue were urgent or 
emergent. Therefore, we decided that the Plan does not have to pay for facial electrolysis treatments provided on January 
4, 2021, to November 29, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Laboratory services provided on February 22, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Laboratory services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says you would like to request reconsideration of the 
denied claim. 
 
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 Laboratory services provided on February 22, 
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 the prolonged evaluation and management service provided 
on January 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the prolonged evaluation and management service. You say that the provider was 
already in-network and does not require authorization. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
 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 did not pre-approve the 
prolonged evaluation and management service. We found no exception that would require the Plan to pay for 
prolonged evaluation and management service. The records provided for review do not show that the services 
at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the prolonged 
evaluation and management service provided on January 31, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services you received on July 12, 
2021. 
 
You asked the Plan to pay for the non-transport ambulance services. You did not provide a specific argument 
with your appeal request. The Plan denied your request. The Plan says non-transport ambulance services are 
not covered. The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance 
services when there is no transport. The ambulance company did not provide transport services on July 12, 
2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the 
Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for non-transport 
ambulance services you received on July 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography, head or brain provided on  
January 14, 2022. 
 
You asked the Plan to pay for a computed tomography, head or brain. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the member's Plan excludes coverage for 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 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a computed tomography, head or brain provided on 
January 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cystourethroscopy. 
 
You asked the Plan to pre-approve cystourethroscopy. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 cystourethroscopy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that under Medicare guidelines, the request is not medically 
necessary because the records show the requested procedure will be performed in the same anatomical region 
accessed through the same orifice during the same encounter. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cystourethroscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve cystourethroscopy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 1-view X-ray exam of the chest (71045) provided on 
November 29, 2021. 
 
You asked the Plan to pay for a chest X-ray. You say that you have provided medical records to support the 
service billed. The Plan denied your request. The Plan says rules for payment have not been met because the 
CPT code at issue is inclusive to another billed code. 
 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 a 1-view X-ray exam of the chest (71045) provided on 
November 29, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services (01922) provided on December 17, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that the provider was certified on the date of service 
to perform the services at issue. The Plan denied your request. The Plan says that rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a rationale to explain why an anesthetist 
cannot provide the services at issue. It is the Plan's responsibility to substantiate its denial. In this case, the 
denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay 
for anesthesia services (01922) provided on December 17, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on December 14, 2021. 
 
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. The rules say that the Cxbladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on December 14, 
2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a computed tomography (CT) scan provided to the enrollee on January 
12, 2022. 
 
You asked the Plan to pay for the services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the plan only reimburses to anesthesia providers. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial in this case, and have not sent in 
evidence to verify their case. The plan says that they only reimburse anesthesia providers for this service. The 
service at issue was for imaging, so this is not a valid denial reason. Therefore, we decided that the Plan has to 
pay for a computed tomography (CT) scan provided to the enrollee on January 12, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on December 14, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 physician services provided on December 14, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Supply allowance for therapeutic continuous glucose monitor 
(cgm) provided on September 17, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Supply allowance for therapeutic continuous glucose monitor (cgm). You say 
that you are appealing with supporting records. The Plan denied your request. The Plan says the services are 
not authorized because this provider is a non-network provider who does not work with the member's health 
plan, and the member was referred by provider who also does not work with the member's plan. The Plan also 
says that the member's primary care physician did not refer for 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 Supply allowance for therapeutic continuous 
glucose monitor (cgm) provided on September 17, 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 Skilled Nursing Facility Care provided on February 28, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Skilled Nursing Facility Care. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 Skilled Nursing Facility Care provided on 
February 28, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on December 13, 2021.