Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 5, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the Plan made 
several attempts to try and obtain the EOB from the members primary insurance and was unsuccessful. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
 
 The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has made several 
attempts to try to obtain the EOB from the primary insurance. As the secondary insurer, the Plan cannot be held 
responsible for psychotherapy until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on May 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve the portable ventilator. You say that the ventilator is medically necessary. 
The Plan denied your request. The Plan says a BiPAP can meet the enrollee's needs. 
 
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 the portable ventilator. Our reviewer 
says that the portable ventilator is not medically necessary. Our physician reviewer found there is no 
documentation of that in the medical record, and no downloaded data to show compliance with use of the 
device as an outpatient. BiPAP has not been tried. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service February 15, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 70544 is bundled into payment for code 70553. 
 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 70544 
is a column II code to column I code 70553. 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 70544 billed for date of service February 15, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 9, 2021, billed with 
codes 81206, 81292, 81295, 81298, 81311, 81317, 81162, 81301, 81191, and 81309. 
 
You asked the Plan to pay for the genetic testing billed. 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. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on August 9, 2021, 
billed with codes 81206, 81292, 81295, 81298, 81311, 81317, 81162, 81301, 81191, and 81309.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on February 17, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that having acted in good faith in your care of 
this patient, you are submitting supporting records to your professional courtesy. The Plan denied your request. 
The Plan says the rendering provider is non-participating and there is not a referring provider. The Plan also 
says that they have also determined that these services were 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a specialist office visit provided on February 17, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 26, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this was medically necessary and should be 
covered. 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 March 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 knee orthosis rendered on January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and accessories 
(E0673) provided on March 24, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this was medically necessary. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. If the base PCD is 
not covered, related accessories are not eligible for reimbursement.   
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and accessories (E0673) provided on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on March 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for anesthesia services. You say that you were not aware that the anesthetist was not 
in-network. You also say that if you had known this, you would not have had the procedure at that facility. You 
also say that you are on social security and cannot afford such an expense of $1,952. The Plan denied your 
request. The Plan says the provider was not in-network. 
 
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 anesthesia services provided on March 8, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this is considered experimental and investigational. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Intracept 
procedure is experimental. More research is needed. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve the Intracept procedure for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF care. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from the IRF care. The 
Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 there is not a reasonable expectation that this enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided 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 IRF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent observation care provided on April 12, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent observation care. You say that this provider regularly complies with 
all administrative requirements for payment. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan, and the services were not referred by a network provider. The Plan also says 
that they have 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 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 observation care provided on April 12, 
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 procedure code 93042 billed for date of service September 4, 
2021. 
 
You asked the Plan to pay for procedure code 93042. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 93042 is bundled into payment for code 99291.  
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 93042 
is a column II code to column I code 99291. 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 93042 billed for date of service September 4, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (33285). 
 
You asked the Plan to pre-approve the implantable loop recorder. You say that this service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an implanted loop recorder is used when syncope is 
thought to be cardiac-related, but is too infrequent to be detected by either a Holter monitor or a traditional pre-
symptom loop recorder. 
 
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 implantable loop recorder. Our 
reviewer says that this procedure is not medically necessary. Our physician reviewer found there is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for this device. 
 
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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder (33285).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF care. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 there is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided 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 IRF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and related 
accessories (E0673) provided on November 24, 2021. 
 
You asked the Plan to pay for a pneumatic compression device and related accessories. You say that the items 
at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for 
payment for PCDs have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Because the base PCD cannot be covered in this case, 
the related accessories are also not eligible for payment. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and related accessories (E0673) provided on November 24, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to verify the copayment and the coinsurance for an office visit and 
radiation therapy services provided from August 10, 2021, to January 11, 2022. 
 
You asked the Plan to verify the copayment and the coinsurance for an office visit and radiation therapy 
services. You say that you had an initial copayment to see a provider, who informed you that you had cancer 
and needed 39 treatments. You also say that you told them you did not need receipts, because your cancelled 
checks would be fine. You also say that some of the amounts on the bill do not coincide with the checks. You 
also say that according to the representative at the facility, it takes them ten days to process a payment. The 
Plan denied your request. The Plan says at the time of service, your maximum out of pocket expenses had not 
been met yet. 
 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 $2,800 
for the maximum out-of-pocket expenses for in-network covered expenses. This benefit includes office visits 
and radiation therapy services.  
 
The cost-sharing amounts you are appealing, along with other cost-sharing amounts you were charged 
throughout the year, met your maximum out-of-pocket amount.  
 
 
2021 Claim Number: Date of Service: Allowed Amount: Cost Share Amount: 
21231E021Z00 August 10, 2021  $1,727.40 $250 
21273E03LJ00 September 9, 2021 $717.97 $143.59 
21291E03BF00 September 23, 2021 $879.78 $175.96 
21354E03KC00 November 29, 2021 $326.29 $65.26 
21354E03G200 December 9, 2021 $2,153.43 $430.69 
22040E02XX00 December 29, 2021 $5,749.70 $1,144.17 
 Total:  $2,209.67 
 
2022 Claim Number: Date of Service: Allowed Amount: Cost Share Amount: 
22040E033M00 January 3, 2022 to January 4, 2022 $3,434.55 $686.91 
22048E02GD00 January 11, 2022, to February 9, 2022 $10,983.45 $2113.09 
 Total:  $2800 
 
Your appeal referenced office visit and radiation therapy services. Office visits fall within the 
physician/practitioner services, including doctors office visits benefit category. You have also been asked to 
pay 20% coinsurance for radiation therapy services. Radiation therapy services 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 verify the 
copayment and the coinsurance for an office visit and radiation therapy services provided from August 10, 
2021, to January 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in 
the setting of chronic low back pain due to lumbar degenerative disc disease have not been demonstrated in the 
peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Intracept 
procedure is experimental. More research is needed. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve the Intracept procedure for the enrollee.