Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the surgical services (27132) provided on December 21, 2020. 
 
You asked the Plan to pay for the surgical services. You say that according to your contract with the Plan, in 
case of emergency, the Plan is supposed to pay for the surgery. You say that you had this procedure in Mexico 
during the peak time of the COVID pandemic and you were unable to return to the United States. The Plan 
denied your request. The Plan says that the services are not covered. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.  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. 
 
We looked at the file and Medicare rules. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request. The file does not show that the Plan 
made any attempts to obtain medical records from the provider on behalf of the enrollee for their medical 
review. The Plan has not provided evidence that these services provided during a time when travel from 
country to country was limited due to COVID that the enrollee could have waited until she returned to the 
United States. Based on this information, we decided that Medicare rules for coverage of the surgical services 
have been met. Therefore, we decided that the Plan has to pay for the surgical services (27132) provided on 
December 21, 2020.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 62290 provided in an Ambulatory Surgical 
Center (ASC) on November 17, 2021. 
 
You asked the Plan to pay for procedure code 62290. You say that the Plan denied this claim incorrectly. The 
Plan denied your request. The Plan says the code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all procedure codes payable in an ASC are listed 
on the Medicare ASC Fee Schedule.  Each code is also assigned an ASC Payment indicator.  Payment indicator 
N1 means that the code is a packaged service/item and no separate payment is made. In this case, the code you 
billed (62290) has a payment indicator of N1 on the ASC fee schedule.  This means that no separate payment is 
made for this code. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 62290 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 62290 provided in an Ambulatory Surgical Center (ASC) on November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses and frames you purchased on November 
23, 2021. 
 You asked the Plan to pay for the progressive lenses and frames. You say that your vision changed rapidly and 
you needed new glasses. The Plan denied your request. The Plan says you had already exhausted your vision 
benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eyewear and lenses once every 24 months.  You already received covered eyeglasses 
and lenses on October 29, 2020.  This limitation exists even if you have a change in vision. 
 
Based on this information, we decided that the Plan's rules for coverage of the progressive lenses and frames 
have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses and frames 
you purchased on November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 7, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this provider is 
out-of-network with the Plan and the ordering physician was also out-of-network with the Plan. 
 
 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 lab services provided on December 7, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided on October 21, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the Plan applied an incorrect denial reason 
to your claim. The Plan denied your request. The Plan says that the service does not meet the coverage 
requirements in the applicable Local Coverage Determination or National Coverage Determinations. 
 
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's extremely limited case file submitted to us includes no 
citation to a specific rule upon which this denial was based. There was no analysis provided by the Plan as to 
what rule was applied and why the services you rendered fit within that rule.  Without this information, we 
cannot determine if the Plan's denial was appropriate.  The burden is on the Plan to support why its denial is 
appropriate.  The minimal information the Plan provided in the case file it submitted to us does not substantiate 
its denial. Therefore, we decided that the Plan has to pay for anesthesia services provided on October 21, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received from an out-of-network dentist 
on January 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are new to the Plan and did not know how 
to locate a network dentist. The Plan denied your request. The Plan says there is no coverage for dental services 
provided by out-of-network dentists. 
 
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. Your Plan contract explicitly 
says that dental services received out-of-network are not covered. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
services you received from an out-of-network dentist on January 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary for the patient. The 
Plan denied your request. The Plan says this drug is not medically necessary and Abraxane has been approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that 
Keytruda is not medically necessary. Our physician reviewer found the use of this drug is not supported by one 
of the major drug compendia or by clinical research for the patient's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (code D0140) you received on January 
20, 2022. 
 
You asked the Plan to pay for the limited oral exam (code D0140). You say that the dentist had to evaluate 
your molar to place a crown on it. The Plan denied your request. The Plan says limited oral exams are not 
covered under your dental benefit. 
 
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. Your Plan dental benefits 
include coverage only for those dental services listed in your Covered Dental Services Chart. Limited oral 
exams (code D0140) are not listed as covered in this chart. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral exam (code D0140) you received on January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. 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 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 March 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are too weak to go home and the hospital has no 
beds for you.  You are currently taking iron infusions and can't take care of yourself. The Plan denied your 
request. The Plan says SNF care is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you have stabilized medically and are ready 
for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily 
basis. You are medically stable and can receive further rehab services at a lower level of care. Although further 
rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services 
can be provided at a lower level of care than a skilled nursing facility. You do not have any parental 
medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any 
acute exacerbations of chronic medical problems. Your physical function is at or near her baseline and she can 
receive services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206 and 81292) provided on 
October 22, 2021. 
 You asked the Plan to pay for codes 81206 and 81292. 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 say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206 and 81292) provided on October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. 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 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 September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low-level laser services and the mechanical traction 
services you received from a chiropractor you received from January 14, 2022, to January 20, 2022. 
 
You asked the Plan to pay for the low-level laser services and the mechanical traction services. You say that 
these services helped your pain and should be covered. The Plan denied your request. The Plan says these are 
not covered chiropractic services. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the low-level laser services and the mechanical traction services you 
received from a chiropractor you received from January 14, 2022, to January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 testing provided on August 8, 2021. 
 
You asked the Plan to pay for the COVID-19 testing. You say that this testing was medically necessary for you 
to travel. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 testing have not been met. Specifically, there is no evidence that this testing was 
ordered by a physician with intent to use the results in the management of a specific medical problem. COVID-
19 testing for voluntary travel is not a Medicare covered benefit. Therefore, we decided that the Plan does not 
have to pay for the COVID-19 testing provided on August 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 2, 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 say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services provided on November 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve outpatient mental health. You say that this provider has helped with your 
depression. The Plan denied your request. The Plan says the services have been requested from an out-of-
network provider that is not licensed in the state of Texas. 
 
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 
outpatient mental health 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 procedure code 99336 provided on January 19, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for procedure code 99336. You say that this provider relied on the facility staff to 
verify eligibility. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 
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 procedure code 99336 provided on January 19, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 93000 billed for date of service August 16, 2021. 
 
You asked the Plan to pay for procedure code 93000. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says that the claim is missing a National Provider 
Identifier. 
 
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 sole basis of the Plan's denial rationale is that an NPI is missing 
from the claim.  However, that does not appear to be true.  The copy of the claim submitted in the case file by 
the Plan shows an NPI is entered on the claim form in field 17b.  The case file submitted had no other 
arguments from the plan and no other information substantiating its denial.  There is no explanation by the Plan 
why the NPI entered in field 17b is inappropriate.  The burden is on the Plan to support its denial and they have 
failed to do so in this case. Therefore, we decided that the Plan has to pay for procedure code 93000 billed for 
date of service August 16, 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 pay for the continuous positive airway pressure (CPAP) machine 
you purchased on November 3, 2021. 
 
You asked the Plan to pay for the CPAP machine. You say that your old CPAP machine had been recalled and 
you needed to have a machine.  You purchased this model because you had it previously and you would like 
reimbursement. The Plan denied your request. The Plan says this item is not covered when purchased. 
 
The Plan must follow Medicare rules. Medicare rules say that for items designated as capped rental items, these 
items must be rented for a certain period of time.  Beneficiaries are then offered an option to purchase in the 
tenth month of rental.  In this case, the CPAP machine you purchased is a capped rental item.  This means that 
Medicare does not cover this item when it is purchased outright.  Therefore, we decided that the Plan does not 
have to pay for the continuous positive airway pressure (CPAP) machine you purchased on November 3, 2021.