Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network services provided to the enrollee on July 22, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 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 out of network services provided to the enrollee on
July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Sprint PNS device.
You asked the Plan to pre-approve a Sprint PNS device. You say that the requested item is a medical necessity
for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral
nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say
that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist.
We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an
implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes
being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as
electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for the requested
item have not been met. Therefore, we decided that the Plan does not have to pre-approve a Sprint PNS device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 21, 2021.

You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your
request. The Plan says there are no authenticated medical records from the ordering provider documenting that
the treating physician had intended the clinical diagnostic testing be performed.

The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be
covered.

The documentation submitted did not include a physician order/lab requisition or medical records stating
exactly what tests were to be performed. 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
laboratory services provided to the enrollee on May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe
gingival inflammation (D4346) provided on June 29, 2021.
You asked the Plan to pay for the scaling. You say that you had an authorization for approval for this service,
but it is still being denied. You also say that you would like this to be approved. The Plan denied your request.
The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's 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 the
scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on June 29,
2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
You asked the Plan to pre-approve Gel-One. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee has not had sufficient conservative therapy.
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when the
patient has failed at least three months of nonpharmacologic therapy such as, but not limited to, home exercise
program, education, weight loss, physical therapy if indicated.
We looked at the file and Medicare rules. The submitted medical records do not document that the enrollee has
had three months of conservative therapy such as a home exercise program or physical therapy. The records
also do not indicate that this is contraindicated for the enrollee. Based on this information, we decided that
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have
to pre-approve Gel-One
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a walking boot (L4361) rendered on April 26, 2021. We also decided that the Plan does not have to waive the copayments for an x-ray of the foot (73630) rendered on May 12, 2021, and again on June 8, 2021.
You asked the Plan to waive the coinsurance for a walking boot. You also asked the Plan to waive the copayments for an x-ray of the foot. You say that you were told that your fee for the outpatient surgery was $275 and then you received a separate charge. You also say these fees should be a part of the surgery fee. The Plan denied your request. The Plan says you were 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% coinsurance durable medical equipment (DME) and related supplies. Your contract with the Plan also says that enrollees must pay a $45 copayment for basic radiological services in a specialist's office or a freestanding radiological facility. You have been asked to pay $36.39 in coinsurance for a walking boot. Walking boots fall within the durable medical equipment (DME) and related supplies benefit category. You also have been asked to pay a $26.73 copayment, which is less than the $45 copayment, for each of two services of an x-ray of the foot. The total copayment of the x-rays of the foot is $53.46 ($26.73 x 2 = $53.46). X-rays of the foot 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 coinsurance for a walking boot (L4361) rendered on April 26, 2021. You also asked the Plan to waive the copayments for an x-ray of the foot (73630) rendered on May 12, 2021, and again on June 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on September 11, 2019.
You asked the Plan to pay for the services provided. You say that the claim was poorly handled. The Plan
denied your request. The Plan says the requested code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, the CPT Code Manual definition of code 23430 is tenodesis of long tendon of biceps. We find that
CPT code 23430 is not supported in the medical record. Specifically, the services described in the medical
records more comprehensively described by billed code 23472. 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 surgery services provided on September 11, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the specimen collection for severe acute respiratory
syndrome Coronavirus 2 (G2023) and infectious agent detection by nucleic acid (U0003) provided on August
19, 2020.
You asked the Plan to pay for the specimen collection and infectious agent detection. The Plan denied your
request. The Plan says when the enrollee is enrolled in a Medicare-certified hospice program, their hospice
services and Part A and Part B services related to their terminal prognosis are paid for by Original Medicare,
not the Plan. The Plan also says that this date of service falls within the hospice enrollment period.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the specimen collection for severe acute respiratory syndrome
Coronavirus 2 (G2023) and infectious agent detection by nucleic acid (U0003) provided on August 19.2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on September 1, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on
September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the refraction provided on May 18, 2021.

You asked the Plan to waive the copayment for the refraction. You say that this was for your yearly routine eye
exam. You say that the Plan pays for one free eye exam per year and insurance should pay the $10 copayment.
The Plan denied your request. The Plan says the copayment applied 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 $10
copayment for each Medicare-covered exam. Covered services include outpatient physician services provided
by an ophthalmologist or optometrist for the diagnosis and treatment of diseases and injuries of the eye.

You have been asked to pay a $10 copayment for the refraction. The refraction falls within the "Vision care"
benefit category. The records show a medical eye exam was performed, which does not fully cover a refraction.
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 the refraction provided on May 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for thirty (30) additional routine transportation
trips (A0120).
You asked the Plan to provide coverage for additional routine transportation trips. You say that you have
prostate cancer, and you have to go to radiation therapy Monday through Friday. You also say you cannot
afford to pay for transportation. The Plan denied your request. The Plan says the benefit has been exhausted.
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 Plan's coverage rules apply in this
case. The Plan covers a maximum of 48 trips per year.
We looked at your request, the records in the case file, and the rules. The records show you have used 48 one-
way transportation trips this year. 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
provide coverage for thirty (30) additional routine transportation trips (A0120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you need around the clock care. The Plan denied
your request. The Plan says that you can safely receive the services you need in other settings.
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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture
after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there
is no documentation of a need for an intensive rehabilitation program. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device
supplies (K0553), provided on April 17, 2021.

You asked the Plan to pay for the CPAP device supplies. You say that the items should be covered. The Plan
denied your request. The Plan says this service was related to a prohibited telemarketing contact.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone
regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the
enrollee's treating physician. The record does not show that written permission was obtained to make contact
by telephone regarding the furnishing of this item. The record does not show that contact was initiated
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the
past 15 months. Based on this information, we decided that Medicare rules for coverage of the CPAP device
supplies have not been met. Therefore, we decided that the Plan does not have to pay for the continuous
positive airway pressure (CPAP) device supplies (K0553), provided on April 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet
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 no documentation that you require the intensive rehabilitation therapy
program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be
appropriate in this case.
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on
August 9, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that you had to go to the ER because the
urgent care was not open. You said that you don't feel as though you should have to pay the copayment because
the ER doctor didn't give you much direction. The Plan denied your request. The Plan says you were charged
this copayment 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 $90
copayment for emergency room visits.

You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason
for your visit or your satisfaction with the services received. 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 the emergency room (ER) visit you had on August 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for urography, retrograde, with or without KUB (74420) provided July 2, 2021.
You asked the Plan to pay for the diagnostic service. You say that the 26 modifier is billable for professional claim and professional claim already paid under 26 modifier to the doctor and you cannot bill 26 in the facility claim. The Plan denied your request. The Plan says the procedure code is inconsistent with the modifier used or a required modifier is missing.
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 74420 is urography, retrograde, with or without KUB. We find that CPT code 74420 is not supported in the medical record. Specifically, per Medicare guidelines, procedure code 74420 describes a diagnostic procedure that requires a professional component modifier in place of service (POS) 24. When billing these services in an inpatient hospital, outpatient hospital, or skilled nursing facility, only the professional component should be billed by the physician. Billing of the technical component is inappropriate by the physician as the facility should be responsible for submitting it. Modifiers 26 and TC can be used with these codes. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for urography, retrograde, with or without KUB (74420) provided July 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 16, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
Review of the file shows that the submitted documentation did not contain a signed physician order. In
addition, there are no medical records from the ordering provider documenting the treating physician had
intended the clinical diagnostic test be performed. This means that the documentation does not support that the
laboratory testing at issue in this appeal was not requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory services provided on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99349) rendered by the out-of-network (OON) provider on August 20, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99349) rendered by the out-of-network (OON) provider on August 20, 2021.