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

 
We decided that the Plan does not have to pay for a nursing facility care visit provided on June 12, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for a nursing facility care visit. You say that you are requesting the claim be 
reviewed and reprocessed for payment. The Plan denied your request. The Plan says an authorization was not 
obtained prior to services rendered. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a nursing facility care visit provided on June 12, 
2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on April 24, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on April 24, 2023.
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 would like enrollee to be at this level of 
rehabilitation so they can get home as soon as possible. You also say that the enrollee would be able to work 
with therapy more often at rehabilitation. The Plan denied your request. The Plan says an admission to an IRF 
is not reasonable and necessary.  
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that 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. Our physician reviewer also found that 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation for a medical appointment. The Plan denied your request. The Plan says your benefit only allows 
24 one-way trips with each one-way trip not exceeding 100 miles of driving distance. 
 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 routine transportation when the driving distance for a one-way trip is within 100 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 161 miles away from your residence. The Plan only covers distances up to 100 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit and laboratory services provided by an out-of-network 
(OON) provider on April 10, 2023, to April 18, 2023. 
 
You asked the Plan to pay for the office visit and laboratory services provided OON. You say that you received 
the services in dispute due to an emergency.  The Plan denied your request. The Plan says that you saw a non-
participating provider without prior authorization and there was no medical emergency.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not provide any medical records or evidence of having 
made reasonable attempts to obtain medical records. The appellant makes the specific argument that the 
services in dispute were emergent in nature. The Plan's denial reason states that the services provided were not 
for an emergency. Without medical records, we are unable to evaluate whether the services in dispute were 
considered emergent. Without this necessary documentation, the Plan has not substantiated their denial reason. 
Therefore, we decided that the Plan has to pay for the office visit and laboratory services provided by an out-
of-network (OON) provider on April 10, 2023, to April 18, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for liquid Gammagard billed for date of service April 5, 2023. 
 
You asked the Plan to pay for the billed services. You say that the item was prior authorized. The Plan denied 
your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Although there is a delivery ticket included, the documentation does 
not indicate what was shipped/delivered. There is insufficient evidence to show that the service at issue was 
delivered to the enrollee. Based on this information, we decided that the Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for liquid Gammagard billed for date of 
service April 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on April 14, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that that codes 0012M and 0013M for Cxbladder are 
non-covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on April 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face mask (A7031) and nasal mask (A7034), purchased 
on August 1, 2022. 
 
You asked the Plan to pay for the face mask and nasal mask. You say that the items should be covered. The 
Plan denied your request. The Plan says these items were purchased through a supplier that is not enrolled in 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the face mask (A7031) and nasal mask 
(A7034), purchased on August 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the inpatient hospital stay provided from 
March 15, 2023, to March 17, 2023. 
 
You asked the Plan to waive the cost sharing for the inpatient hospital stay. You say that you had the same 
procedure last year with no copayment. 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. Your 
contract with the Plan says that there is a $150 deductible which applies to inpatient hospital stays. Your 
contract with the Plan also says that you must pay 10% coinsurance after meeting the deductible for each 
inpatient hospital stay. 
 
You have been asked to pay $150 towards the deductible. The item or service you asked the Plan to waive the 
cost sharing for falls within the inpatient hospital care benefit category. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is a $150 deductible which applies to inpatient hospital stays. 
This cost sharing is a contractual obligation that had not been met at the time the inpatient hospital stay was 
received from March 15, 2023, to March 17, 2023.  
 
Due to meeting the $500 maximum for certain types of services, you have been asked to pay $300.58, which is 
less than the standard 10% coinsurance for the inpatient hospital stay. You have been asked to pay a total of 
$450.58 ($150 deductible + $300.58 coinsurance = $450.58). 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 cost sharing 
for the inpatient hospital stay provided from March 15, 2023, to March 17, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE) (93306). 
 
You asked the Plan to pre-approve a TTE. The Plan denied your request. The Plan says this request is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an echocardiography performed for screening 
purposes 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 pre-approve a TTE. Our physician reviewer found at 
issue is the medical necessity of a TTE, essentially for screening purposes, in the absence of any apparent 
significant change in the patients clinical condition or examination. Clinical guidelines do not support 
performing a TTE in this setting. Our reviewer found that in summary, there is no supportive evidence for the 
medical necessity of a TTE in this patients clinical management. 
 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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiography (TTE) (93306).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #29 provided on June 12, 
2023. 
 
You asked the Plan to pay for the dental service. You say that the provider did not tell you that the core buildup 
was not covered. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the core buildup is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950) for tooth #29 provided on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat L3-L5 radiofrequency ablations (RFAs). 
 
You asked the Plan to pre-approve repeat RFAs. You say that the enrollee has failed conservative treatment 
and needs this for pain relief and quality of life. The Plan denied your request. The Plan says the previous RFA 
provided only 2 months of pain relief. 
 
The Plan follows Medicare rules. Medicare rules state that repeat RFAs are only covered if certain criteria are 
met. 
 
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 repeat RFAs. Our reviewer says that the 
enrollee does not meet criteria for repeat RFAs. Our physician reviewer found Medicare criteria require 6 
months of pain relief following RFA. Here, only 2 months were achieved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat RFAs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat L3-L5 radiofrequency ablations (RFAs).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 28, 2023, billed with 
codes 87641, 87653, 87500, 87640, 87481, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that these are the codes you bill for the panel. 
The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
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. The file shows that a urinary tract infection panel test was provided. We looked at the file and Medicare rules. 
This NGS panel test was not billed with a single 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 March 28, 2023, billed with codes 87641, 87653, 
87500, 87640, 87481, and 87798.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lower limb prosthesis addition (L5673) provided on April 
13, 2023. 
 
You asked the Plan to pay for the lower limb prosthesis addition (L5673). You say that the item should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the lower limb 
prosthesis addition (L5673) provided on April 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on April 17, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953) and oral surgery 
procedure (D7999) for tooth #19 and #20. 
 
You asked the Plan to pre-approve the dental services. You say that you need your teeth extracted and you are 
in pain. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because they are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 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 dental services. Our reviewer says 
that the bone replacement graft and material is not medically necessary. Our physician reviewer found that the 
removal of affected teeth is necessary for the health of the enrollee. Ridge preservation is not necessary though 
if an implant is anticipated it can be beneficial. The Plan does not cover ridge preservation procedures; 
however, an implant may be able to be placed at a later time even without the bone procedure. It may have 
some benefit in certain circumstances; however, the bone replacement procedures are not medically necessary. 
 
The Plan does not provide coverage for bone replacement when removing a tooth. The covered services are 
listed in the Plan materials and does include surgical removal of teeth which was a primary need of the 
enrollee. The requested bone grafting procedure however is not listed in the Plan materials and is not 
considered a covered service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a bone replacement graft (D7953) and oral surgery procedure (D7999) for tooth #19 
and #20.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility care visit provided on June 23, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for a nursing facility care visit. You say that you are requesting the claim be 
reviewed and reprocessed for payment. The Plan denied your request. The Plan says an authorization was not 
obtained prior to services rendered. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a nursing facility care visit provided on June 23, 
2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on April 25, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for home health agency care provided on March 
14, 2023, to April 5, 2023. 
 
You asked the Plan to waive the cost share for home health agency care. You say that you disagree with the 
cost share. 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. Your 
contract with the Plan says that there is a $600 deductible which applies to home health agency care.  
 
The item or service you asked the Plan to waive the cost share for falls within the home health agency care 
benefit category. You are being asked to pay your $600 deductible. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $600 deductible which applies to home health agency care. This 
cost sharing is a contractual obligation that had not been met at the time home health agency care was received 
on March 14, 2023, to April 5, 2023. Therefore, we decided that the Plan does not have to waive the cost share 
for home health agency care provided on March 14, 2023, to April 5, 2023.