Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy (97140), therapeutic exercises (97110), 
therapeutic activities (97530), and the hot or cold packs therapy (97010) rendered by the out-of-network 
(OON) provider on March 1, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization. 
 
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 had network providers available 
who could have provided the services at issue in this appeal. 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 the manual therapy (97140), therapeutic exercises (97110), therapeutic activities 
(97530), and the hot or cold packs therapy (97010) rendered by the out-of-network (OON) provider on  
March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ophthalmological service provided on April 4, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an ophthalmological service. You say that the provider is in-network. The Plan 
denied your request. The Plan says the provider is out-of-network, and it was determined these services were 
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 ophthalmological service provided on April 4, 
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 mastectomy sleeve (L8010) and a gradient pressure 
aid (S8424). 
 
You asked the Plan to pre-approve a mastectomy sleeve (L8010) and a gradient pressure aid (S8424). You say 
that the patient suffers from left upper extremity lymphedema as a result of a mastectomy. The Plan denied 
your request. The Plan says these items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that mastectomy sleeves are non-covered.  In 
addition, the other item requested was requested with an 'S' code.  These codes are not valid for Medicare 
purposes. Based on this information, we decided that Medicare rules for coverage of a mastectomy sleeve 
(L8010) and a gradient pressure aid (S8424) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a mastectomy sleeve (L8010) and a gradient pressure aid (S8424).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided from May 7, 2022, to May 8, 2022. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan 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 an office visit provided from May 7, 2022, to May 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 13, 2022, 
and April 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that it is the responsibility of the 
enrollee's referring physician or the nursing facility to obtain prior authorization. You say that the provider 
furnishes services in good faith and should be paid for the services provided. Additionally, a prior authorization 
cannot always be obtained in a timely manner due to the urgency of care. The Plan denied your request. The 
Plan says the rendering provider is out-of-network, and no authorization was obtained prior to rendering the 
services to the enrollee. Furthermore, the services were not referred by a participating provider. 
 
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 subsequent nursing facility care provided on April 
13, 2022, and April 20, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biologic material and osseous tissue regeneration (D4265) 
provided by a participating provider on May 11, 2022. 
 
You asked the Plan to pay for biologic material and osseous tissue regeneration. You say that you were in a lot 
of pain, and you needed these services done. The Plan denied your request. The Plan says the rendered dental 
service is not a covered 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. 
 
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 biologic 
material and osseous tissue regeneration (D4265) provided by a participating provider on May 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 80307, 83789 and G0480 
provided on March 15, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee is prescribed medication in 
which drug testing is needed to monitor possible opioid use. Please review. The Plan denied your request. The 
Plan says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before 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 the laboratory services coded as 80307, 83789 and 
G0480 provided on March 15, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to a LTACH is medically 
necessary. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and are able to be furnished safely and effectively 
only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the enrollee for a hospital bed (E0291), bed side rails 
(E0310), and a powered pressure reducing mattress pad (E0291) purchased on December 31, 2021, from an 
out-of-network (OON) provider. 
 
You asked the Plan to reimburse the enrollee for a hospital bed and accessories. You say that you believe the 
hospital bed should be covered. The enrollee greatly benefits from the using the hospital bed and can maintain 
a better-quality life. The Plan denied your request. The Plan says the durable medical equipment (DME) was 
purchased from an out-of-network provider and without first obtaining a prior authorization. The Plan says 
there are network DME suppliers available that can dispense covered items. 
 
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 reimburse 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 reimburse for these items/services. 
Therefore, we decided that the Plan does not have to reimburse the enrollee for a hospital bed (E0291), bed side 
rails (E0310), and a powered pressure reducing mattress pad (E0291) purchased on December 31, 2021, from 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88360 billed for date of service April 4, 
2022. 
 
You asked the Plan to pay for procedure code 88360. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 88360 is bundled into 
payment for code 88381. 
 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 88360 
is a column II code to column I code 88381. 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 88360 billed for date of service April 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 13, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly. The Plan 
denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 procedure code 70450 billed for date of service August 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the ventilator at issue meets all Medicare criteria for medically 
necessary and reasonable for this enrollee. Provided records document that the home ventilator is being 
requested for use in average volume assured pressure support (AVAPS) mode with auto-titration which could 
be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and a back-up rate.  As stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide continuous positive 
airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be denied 
as not reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram, routine ECG with at least 12 leads 
provided on June 2, 2022. 
 
You asked the Plan to pay for the ECG. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, 
nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan 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 an electrocardiogram, routine ECG with at least 12 leads 
provided on June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit and routine venipuncture provided on June 3, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for office visit and routine venipuncture. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says the services were provided out-of-network and 
were not approved in advanced. 
  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 office visit and routine venipuncture provided on 
June 3, 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 acupuncture services provided on May 6, 2022, to June 20, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for acupuncture services. You say that you were not aware that you had to get pre-
authorization prior to seeing the provider. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advanced. 
 
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 acupuncture services provided on May 6, 2022, to 
June 20, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from April 1, 2022, to May 16, 
2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. In this case, the Plan has denied payment by stating that the RAP was not 
submitted timely. However, as of January 1, 2022, providers are no longer submitting RAPs. Therefore, no 
RAP was required for this claim and the Plan is citing outdated rules that do not apply to the claim in question. 
Therefore, we decided that the Plan has to pay for the home health services provided from April 1, 2022, to 
May 16, 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis and 
a CT scan of the chest. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis and a CT scan of the chest. You say 
that the services are necessary. The Plan denied your request. The Plan says that based on the documentation 
provided, coverage criteria has not been met. 
 
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 pre-approve a CT scan of the abdomen and pelvis 
and a CT scan of the chest. Our reviewer says that the services are medically necessary. Our physician reviewer 
found all of the clinical and imaging findings point to a highly probable ovarian malignancy such as cystic or 
serous cystic adenocarcinoma of the ovary.  The CT battery of requested tests is highly indicated prior to 
surgical resection and treatment. 
 
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 CT scan of the abdomen and pelvis and a CT scan of the chest have been met. 
Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis and a CT scan of the chest.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services provided on May 6, 2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that you were unconscious and 
your wife feared you had a stroke.  When you woke, you chose to remain at home instead of going to the 
hospital.  You believe that these services should be covered. 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 May 6, 2022. 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 provided on 
May 6, 2022.