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

 
We decided that the Plan does not have to pay for a pelvic exam provided on March 7, 2023. 
 
You asked the Plan to pay for the pelvic exam. You say that you are at a high risk of ovarian cancer as your 
mother died of that disease. The Plan denied your request. The Plan says the benefit allows cervical and vaginal 
cancer screenings once every 24 months and for high risk once every 12 months. The provider billed with a 
diagnosis code of Z01.419 (Encounter for gynecological examination (general) (routine) without abnormal 
findings), which is considered a low-risk diagnosis code and covered every 24 months 
 
The Plan contract says the Plan covers Pap tests and pelvic exams once every 24 months. 
 
We looked at the file and the Plans rules. The file shows that you have exceeded the benefit limit. Based on 
this information, we decided that Plans rules for coverage of the pelvic exam have not been met. Therefore, we 
decided that the Plan does not have to pay for a pelvic exam provided on March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by a chiropractor on March 14, 2023. 
 
You asked the Plan to pay for the office visit. You say that when your doctor went on vacation you needed a 
new chiropractor. The Plan denied your request. The Plan says that the only covered chiropractic service is 
manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided by a chiropractor on March 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87634, 87798, and 87186 billed for date of 
service March 15, 2023. 
 
You asked the Plan to pay for procedure codes 87634, 87798, and 87186. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 87634 is 
bundled into payment for code 87798. Additionally, the records do not describe what test the not otherwise 
specified code 87798 was used for. Lastly, the records do not support the units billed for procedure code 87186. 
 
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 87634 
is a column II code to column I code 87798. The records do not support the modifier billed to bypass the edit. 
Additionally, the records do not describe what test the not otherwise specified code 87798 was used for. Lastly, 
the records do not support the units billed for procedure code 87186. 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 codes 
87634, 87798, and 87186 billed for date of service March 15, 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 the requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says you do not meet all the requirements for admision to an IRF.  
 
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 documentation does not support the necessity for admission to an IRF. The 
complexity of the enrollees medical, rehabilitation, and nursing needs does not require an acute hospital 
inpatient rehab stay with an interdisciplinary approach to rehabilitative care. The enrollees rehabilitation needs 
can be safely provided in an alternate and low intensity setting.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87635 rendered on May 22, 2023. 
 
You asked the Plan to pay for procedure code 87635. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
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 procedure code 87635 rendered on May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87634 and 87798 billed for date of service 
February 15, 2023.  
 
You asked the Plan to pay for procedure codes 87634 and 87798. The Plan denied your request. The Plan says 
the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87634 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. The MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 
14 units of this code, exceeding the MUE. You did not provide all the required evidence showing that the 
excess units were actually provided, were correctly coded, and were medically necessary. Based on this 
information, we decided that Medicare rules for coverage of procedure code 87634 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87634 and 87798 billed for date 
of service February 15, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 31, 2023, to 
February 6, 2023, by an OON provider.  
 You asked the Plan to pay for home health services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 home health services provided on January 31, 
2023, to February 6, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical imaging provided June 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 11, 2023. 
Therefore, we decided that the Plan does not have to pay for periapical imaging provided June 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you were seen by the provider for the last three 
years. The Plan denied your request. The Plan says the provider is an out-of-network dermatologist. They 
redirected you to their in-network dermatology office. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nivolumab. 
 
You asked the Plan to pre-approve Nivolumab. You say that the medication could help the enrollee. The Plan 
denied your request. The Plan says the medication is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Nivolumab. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a 
diagnosis of Stage IV esophageal cancer. The record indicates that the enrollee had progression of the disease 
while receiving the requested drug. The Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a 
supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from 
Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not 
satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nivolumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nivolumab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 23, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the service 
provided. 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 an office visit provided 
on February 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors identified with code E2311. 
 
You asked the Plan to pre-approve electronic connection between wheelchair controller and two or more power 
seating system motors. You say that you disagree with the Plan's denial. The Plan denied your request. The 
Plan says the requested item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that electronic connection between wheelchair 
controller and two or more power seating system motors is only covered for certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee is able to control the power 
options with their own switches. This means there is no need to control the power option through the joystick. 
Based on this information, we decided that Medicare rules for coverage of electronic connection between 
wheelchair controller and two or more power seating system motors have not been met. Therefore, we decided 
that the Plan does not have to pre-approve electronic connection between wheelchair controller and two or 
more power seating system motors identified with code E2311.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 16, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on March 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injection provided on April 11, 
2023. 
 
You asked the Plan to waive the coinsurance for the drug injection. You say that you were told you would have 
a $0 copayment for this injection. 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 10% 
coinsurance for Medicare Part B drugs. 
 
You have been asked to pay 10% coinsurance for the drug injection. This item/service falls within the 
Medicare Part B 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. Your contract with the Plan states enrollees pay a maximum of $300 each quarter for 
Medicare Part B drugs. Therefore, you have only been asked to pay $300, which is less than the standard 10% 
coinsurance for this injection. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the drug injection provided on April 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable harness upgrade with electronic 
connection. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 services are not medically necessary. Our physician reviewer found the records document the enrollee has three out of five right upper extremity strength and is independent with eating; therefore, he has adequate upper 
extremity strength and function to operate the wheelchair's approved power options with their own switches. 
The requested expandable harness upgrade with electronic connection is not medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an expandable harness upgrade with electronic connection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 27, 2023, billed 
with procedure code 23430-59-RT. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this service is part of the primary procedure and 
ineligible for separate pay. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, no medical records have been provided for review. Therefore, we decided that the Plan 
does not have to pay for practitioner services provided on February 27, 2023, billed with procedure code 
23430-59-RT.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for radiation therapy provided from December 
12, 2022, to December 28, 2022. 
 
You asked the Plan to reduce the copayment for radiation therapy. You say that the enrollee is being charged 
two copayments per visit and should only be charged one. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $60 copayment for each radiation therapy service.  
 
 
  The enrollee has been asked to pay a $360 copayment for radiation therapy services ($60 per radiation service 
x 2 services per visit = $120 per visit x 3 visits = $360). This item/service falls within the outpatient diagnostic 
tests benefit category. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for radiation therapy 
provided from December 12, 2022, to December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (00104) provided on August 12, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this 
service is packaged. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code 00104 is not supported in the medical record. Specifically, code 00104 is 
assigned a status indicator of N under the Outpatient Prospective Payment System (OPPS). This means that 
payment for this code is packaged into payment for other services. 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 the services (00104) provided on August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that it is medically necessary. The Plan denied your 
request. The Plan says the requested provider is an out-of-network provider with your insurance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.