Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring and 
related services provided on September 29, 2020. 
 
You asked the Plan to pay for intraoperative neurophysiology monitoring services. You say that this claim was 
submitted correctly with accurate information. The Plan denied your request. The Plan says the information on 
this corrected claim is not accurate, and the submitted original claim number is not a complete or valid number. 
The original claim cannot be found, and this claim submission is passed the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for intraoperative neurophysiology monitoring services was not filed until 
November 18, 2021. There corrected claim information does not bring up a previously submitted claim to show 
that this claim was filed timely. This means that more than one calendar year from the date of service had 
passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for continuous 
intraoperative neurophysiology monitoring and related services provided on September 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the diabetic shoes. 
 
You asked the Plan to pre-approve the diabetic shoes. You say that the item is medically necessary. The Plan 
denied your request. The Plan says insufficient documentation was obtained to determine medical necessity of 
the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the diabetic shoes have been met. 
Specifically, there were no medical records submitted to determine the medical necessity of this item. 
Therefore, we decided that the Plan does not have to pre-approve the diabetic shoes.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the records should support the 
necessity of the requested item. The Plan denied your request. The Plan says Medicare criteria for medical 
supplies do not cover support stockings. Neither Medicare nor the plan covers the stockings. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (43420) provided November 10, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the records do not support the code 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. 
 
In this case, the CPT Code Manual definition of code 43420 is Closure of esophagostomy or fistula. 
 
We find that CPT code 43420 is not supported in the medical record. Specifically the operative report does not 
describe closure of esophagostomy or fistula. Based on this information, we decided that Medicare rules for 
coverage of the surgical services have not been met.  
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for surgical services (43420) provided November 10, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on January 20, 2022. 
 
You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says this 
provider is not contracted with the Plan and you did not request preauthorization. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 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. 
  
We looked at the file and the Plan's rules. The file shows that an authorization was not obtained for the hearing 
aids. The file also shows that this provider is not a network provider with the Plan. Based on this information, 
we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the 
Plan does not have to reimburse you for hearing aids provided on January 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric services provided from October 4, 2021, 
though October 13, 2021. 
 
You asked the Plan to pay for inpatient psychiatric services. The Plan denied your request. The Plan says the 
medical records do not support the need for continued stay to receive inpatient psychiatric services. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric services. Our reviewer 
says that inpatient psychiatric services are not medically necessary. Our physician reviewer found that based 
upon review the records provided it was not expected this enrollee would improve in a reasonable period of 
time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual 
hallucinations and without aggressive behaviors while not showing any acute threats of safety. It did not appear 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather 
than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, 
auditory or visual hallucinations or abnormal behaviors. The health Plans denial of continued inpatient 
psychiatric services appears appropriate. This enrollee did not require inpatient mental health treatment beyond 
the dates in question as noted above as he was not a danger to himself or others and did not have any delusions, 
auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in 
question. It did not appear that the services for the dates in question were reasonably expected or medically 
necessary to improve the patients condition or for the purpose of diagnosis. It appears that the services were 
supervised and evaluated by a physician. Based upon review the records provided, this enrollee does not meet 
the criteria for treatment in an acute inpatient mental health treatment and could have been treated in a lesser 
restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression being cooperative and compliant while not 
showing any acute threats to safety. 
                                                                                                                              
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient psychiatric services provided from October 4, 2021, though 
October 13, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from May 24, 2021, to June 22, 2021. 
 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 there was no daily skilled nurse or therapist need. 
 
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 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 the 
enrollee no longer qualified for or required SNF coverage. The enrollee did not have documented skilled 
nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not 
required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs, as a practical matter, could be provided 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from May 24, 2021, to June 22, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on March 3, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that this should be a tier 1 $0 
copayment since the labs were ordered by your primary care physician. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
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 $20 
copayment for tier 2 laboratory services.  
 
The Plan confirmed that the hospital and ordering physician are tier 2 providers. You have been asked to pay 
$14.63, which is less than the $20 copayment for laboratory services. Laboratory services fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 laboratory services provided on March 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the head and neck 
provided on January 14, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that this is covered under your 
Medicare coverage. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 $165 
copayment for radiological diagnostic services, including ultrasounds.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $144.04, which is less than the $165 copayment for an ultrasound. An ultrasound falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 ultrasound of the head and neck provided on 
January 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent 150MG/ML injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Praluent is on the self-administered drug list and is excluded from coverage under 
Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Praluent 150MG/ML 
injection.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 22, 2021, to 
July 13, 2021. 
 
You asked the Plan to pay for the home health care. You say that payment should be made. The Plan denied 
your request. The Plan says the provider did not submit their RAP or final claim within the required 5 days of 
the start date and from date. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, June 22, 2021. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from June 22, 2021, to July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services ( 81230, 81240, 81241, 81249, 81291, 81408, 
81335) provided February 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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. The records do not show that the treating physician ordered the lab 
tests at issue. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services ( 81230, 81240, 81241, 
81249, 81291, 81408, 81335) provided February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve podiatry services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve podiatry services. You say that you did not care for the provider that you 
were referred to, and you want to see this provider. You also say that you are unwilling to travel far for your 
appointments. The Plan denied your request. The Plan says there is another podiatrist within the distance 
guidelines to your home. 
 
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 
podiatry services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on February 20, 2022. 
  You asked the Plan to pay for the CT scan (70450). You say that the enrollee had multiple exams on this date 
of service. You say that the attached reports support the level of service, and the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says an appropriate modifier was not billed with this 
code edit. 
 
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 CT scan (70450) provided on February 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and appropriate for 
transfer to LTACH. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient 
care and is currently unstable for transfer to the LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
and 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a exercise stationary bike. 
 
You asked the Plan to pre-approve a stationary bike. You say that you disagree with the plan's denial. The Plan 
denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a exercise stationary bike.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital inpatient provided from June 26, 
2021 to June 30, 2021. 
 
You asked the Plan to waive the copayment for hospital inpatient. You say that you were admitted for five 
days. You say that you were told by two patient representatives that there would not be a bill due to COVID-19 
related. The Plan denied your request. The Plan says you have been charged the correct copayment amount. 
 
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 $150 
copayment per day, days 1-5; $0 per day, days 6-90; $0 copayment for additional days at an in-network 
hospital and 40% per stay at an out-of-network hospital. 
 
 You have been asked to pay a total of $1,260 for the inpatient stay ($315/day x 4 days = $1,260). The inpatient 
stays falls within the Inpatient hospital care benefit category. The records show you were charged the in-
network rate for the inpatient stay. 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 hospital inpatient 
provided from June 26, 2021 to June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F5 Leiden gene testing services (81241). 
 
You asked the Plan to pre-approve F5 Leiden gene testing services. You say that this testing is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for the requested 
genetic testing was not 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 F5 Leiden gene testing services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a 65 year old male with provoked deep venous thrombosis 
after surgery. In this case, routine evaluation for hypercoagulable disorders in unselected patients with a 
diagnosis of venous thromboembolism is not warranted. The requested testing is not medically reasonable and 
necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of F5 Leiden gene testing services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve F5 Leiden gene testing services (81241).