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

 
We decided that the Plan does not have to pay for radiology services provided on May 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON radiology services. You say that your organization was not able to get 
authorization for this service due to the quick need to provide the service. The Plan denied your request. The 
Plan says neither your organization nor the ordering provider is a contract provider with the Plan.  
Unauthorized, out-of-network services are 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 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 radiology services provided on May 19, 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 ventilator. 
 
You asked the Plan to pre-approve a 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You have chronic obstructive pulmonary disease (COPD) and was recently admitted with an 
exacerbation. There are no pulmonary function tests to assess severity. Arterial blood gas (ABG) was 
consistent with acute on chronic hypercarbic respiratory failure. You likely have chronic carbon dioxide (CO2) 
retention and may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep. But Medicare does not cover a home ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 15, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on May 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 procedure code 95937 is not supported. 
 
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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
We find that CPT code 95937 is not supported in the medical record. Specifically, the records show that Train 
of Four testing was performed and there is a more appropriate code for these services. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the testing services rendered on May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services provided on August 18, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth services. You say that it was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says the rendering provider is an OON provider and there was 
no approved 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 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 telehealth services provided on August 18, 
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 rendered on January 20, 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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required -26 
modifier to allow for separate PC payment. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the health club membership (S9970) provided from April 17, 
2022, to June 17, 2022. 
 
You asked the Plan to pay for the health club membership. You say that you would like this membership to be 
paid through June. The Plan denied your request. The Plan says health club memberships are not covered under 
your benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits.  
 
The services at issue in this appeal are gym benefits. Therefore, we decided that the Plan does not have to pay 
for the health club membership (S9970) provided from April 17, 2022, to June 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you need at least 15 round trips for 
the rest of the 2022 plan year. The Plan denied your request. The Plan says your benefit plan does not cover 
more than 40 one-way trips per plan year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 40 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a companion robotic dog. 
 
You asked the Plan to pre-approve a companion robotic dog. You say that the enrollee would benefit from 
having a companion robotic dog. You feel this would be an important support for the enrollee's physical and 
mental health. The Plan denied your request. The Plan says the enrollee does not meet the 3 qualifying 
conditions to receive SSBCI benefits. The enrollee is not a high risk for hospitalization per attestation 
submitted by provider. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a companion robotic dog have not been met. Specifically, we have confirmed that you do not have 
one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not 
have to pre-approve a companion robotic dog.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for infusion therapy provided from March 4, 
2022, to April 12, 2022. 
 
You asked the Plan to waive the copayment for infusion therapy. You say that you paid the office copayments 
and the coinsurances for the drugs on the dates of services you went into the provider's office. You also say that 
the drugs were administered to you at home by your spouse. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that home infusion therapy 
involves the intravenous or subcutaneous administration of drugs or biologicals to an individual at home. The 
components needed to perform home infusion include the drug (for example, antivirals, immune globulin), 
equipment (for example, a pump), and supplies (for example, tubing and catheters). Your contract with the Plan 
also clearly says that the enrollee will pay the cost-sharing that applies to primary care services, specialist 
physician services, or Home Health (as described under Physician/Practitioner Services, Including Doctors 
Office Visits or "Home Health Agency Care") depending on where you received administration or monitoring 
services. Your contract with the Plan also says you must pay a $25 copayment for services obtained from a 
specialist.  
 
You have been asked to pay a $25 copayment for each infusion therapy, which is a total of $850 ($25 
copayment x 34 days of home infusion therapy = $850). This item/service falls within the services obtained 
from a specialist benefit category. The record shows that these services were monitored, and the infusion drugs 
were dispensed by the provider. 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 infusion therapy provided 
from March 4, 2022, to April 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services rendered on May 6, 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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is made for an assistant at surgery when 
the procedure is authorized for an assistant and the person performing the service is a physician, physician 
assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS). 
 
We looked at the file and Medicare rules. Review of the record shows that the provider is not a physician, PA, 
NP, or CNS. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services 
rendered on May 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 10, 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. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on June 10, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for self-administered Medicare covered Part B drugs and other Medicare covered items. These 
drugs are covered under Part B of Original Medicare. Members of our plan receive coverage for these drugs 
through our plan. Covered drugs include drugs that usually arent self-administered by the patient and are 
injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. 
The provider billed in the amount of $11,679.76 and the allowed amount is $4,600.62. $4,600.62 x 20% = 
$920.12. Therefore, resutls in the total cost sharing amount of $920.12. 
 
 
 You have been asked to pay a 20% coinsurance for Part B drugs. This item/service falls within the Medicare 
Part B prescription drugs 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 coinsurance for Part B 
drugs on June 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Hetlioz capsule. 
 
You asked the Plan to pre-approve Hetlioz. You say that the requested drug is a medical necessity for you. The 
Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Hetlioz 
capsule.  
 
  Benefits for Hetlioz 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee can receive care in another setting such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have complex nursing or rehabilitation needs. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathogen panel testing provided on June 7, 2022. 
 
 
You asked the Plan to pay for the services provided. You say that the records show medical necessity. The Plan 
denied your request. The Plan says the testing exceeds the enrollee's needs. 
 
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 pay for the services provided. Our physician 
reviewer found that commercial stool panels are widely available for convenience. While validated, these 
panels are however often overreaching and overly broad. The available records do not support that the 
enrollees loose stool was complicated, nor characterized by electrolyte abnormalities, dehydration, occult or 
visible blood. Patient and provider convenience do not justify by conventional definition of "medical necessity" 
a shot-gun diagnostic approach in routine testing of uncomplicated diarrheal illness in lieu of more directed 
stool analysis. Astrovirus as found is a common diarrhea-causing agent often associated with fruits and 
vegetables.  In this enrollees case, their diarrhea started after eating a salad. Therefore, the provided testing 
was not medically reasonable or 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 the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the pathogen panel testing provided on June 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says admission to the IRF 
was denied as not meeting criteria, is not medically necessary, and a lower level of care might be appropriate. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for infection of the foot and had a trans metatarsal amputation of the foot. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee may benefit from 
additional multiple therapies, including physical and occupational therapy, the documentation does not reveal 
they require this therapy on an intensive IRF level. Medically necessary care can be provided a in a different 
level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.