Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional hour of home health aide services. 
 
You asked the Plan to pre-approve the aide services. You say that you are requiring additional assistance from 
the home health aide for 3 hours daily due to a condition in  your leg. The Plan denied your request. The Plan 
says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found based on the 
limited documentation provided you do not have documented skilled therapy needs. The services are not shown 
to be medically necessary to assist in the treatment of an acute illness or injury.  
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an additional hour of home health aide services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VivAer Arc nasal surgery. 
 
You asked the Plan to pre-approve VivAer Arc nasal surgery. You say that you have tried many other 
treatments to no avail. The Plan denied your request. The Plan says this procedure is unproven. 
 
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 VivAer Arc nasal surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have chronic sinusitis and nasal obstruction. There is insufficient 
literature to support the safety and efficacy of the requested service for your specific conditions.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VivAer Arc nasal surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve VivAer Arc nasal surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided on 
September 15, 2022. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you had outpatient 
surgery. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day, for days 1 to 5 and a $0 copayment for additional days for each in-network Medicare-
covered hospital admission. 
 
 You have been asked to pay a $325 copayment for 1 day of the inpatient hospital stay. This item/service falls 
within the inpatient hospital care 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 reduce the copayment for 
the inpatient hospital stay provided on September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97811, 97814), manual therapy 
(97140), and the infrared therapy (97026) provided on November 2, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says you have exhausted the allowable benefit for 
the services provided in this case. Additionally, the infrared therapy provided was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case. Additionally, Medicare rules say that there is sufficient evidence to conclude the 
use of infrared therapy devices and any related accessories is not reasonable and necessary. 
 
We looked at the file and Medicare and the Plans rules. Based on this information, we decided that the rules 
for coverage of these services have not been met. Specifically, the Plans contract states that supplemental 
coverage is provided for 20 routine acupuncture and chiropractic visits per year. The record shows that the Plan 
has provided coverage for 20 routine acupuncture and chiropractic visits this calendar year. Therefore, the 
enrollee has exhausted the allowable benefit for these services. Additionally, Medicare rules say that there is 
sufficient evidence to conclude that the use of infrared therapy devices and any related accessories is not 
reasonable and necessary. Therefore, we decided that the Plan does not have to pay for the acupuncture 
treatments (97811, 97814), manual therapy (97140), and the infrared therapy (97026) provided on November 2, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telemedicine visit provided on February 23, 2023. 
 
You asked the Plan to pay for a telemedicine visit. You say that the enrollee was in a nursing home at the time 
that the services were rendered. 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 a telemedicine visit 
provided on February 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 15, 2021. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration for the services 
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 office visit provided on 
September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and an x-ray provided on February 08, 2023. 
 
You asked the Plan to pay for an office visit and an x-ray. You say that you are requesting reconsideration of 
the denied claim. 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 and an x-
ray provided on February 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277 x80) and 
physician attendance and supervision of hyperbaric oxygen therapy, per session (99183 x20). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy and physician attendance. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no 
specific clinical rational for hyperbaric oxygen therapy. The review has determined that the enrollee does not 
meet the coverage criteria detailed in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy and physician attendance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277 x80) and 
physician attendance and supervision of hyperbaric oxygen therapy, per session (99183 x20).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pain management office visit provided on January 04, 
2023. 
 
You asked the Plan to pay for a pain management office visit. You say that this was medically necessary and 
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 a pain management 
office visit provided on January 04, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing code 87631 billed for date of service December 6, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for lab testing code 87631 billed 
for date of service December 6, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided from 
February 9, 2023, to February 10, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you cannot afford the 
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 (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for emergency room services. 
 
 
 
 You have been asked to pay a $120 copayment for the emergency room visit. This item/service falls within the 
emergency care 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 copayment for the emergency room visit 
provided from February 9, 2023, to February 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
February 2, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visits on March 10, 2023, to March 
24, 2023.  
 
You asked the Plan to waive the copayments for office visits. You say that you should not have a copayment 
because you were seen by a different provider. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
 
 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for each covered visit or consultation in an outpatient location with a specialist. Covered services 
include medically necessary medical care or surgery services furnished in a physicians office, certified 
ambulatory surgical center, hospital outpatient department, or any other location consultation, diagnosis, and 
treatment by a specialist. There were three visits. 3 x $45 = $135. Therefore, resutls in the total cost sharing 
amount of $135. 
 
You have been asked to pay a $45 copayment for each office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 copayments for office visits on March 10, 2023, to March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an echocardiography, transthoracic, real-time with 
image documentation (2D), includes M-mode recording, when performed (93306). 
 
You asked the Plan to pre-approve echocardiography. You say that the procedure is medically necessary. The 
Plan denied your request. The Plan says the records do not show any new change in the enrollee's status or 
symptoms since her last echocardiogram in November 2022, which showed stable heart function compared to 
the echocardiogram in 2020. The request is 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 echocardiography. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of a previous TTE. At issue is the medical necessity of a 
repeat TTE, in the absence of any apparent significant change in the enrollee's clinical condition. Clinical 
guidelines do not support repeating a TTE with no intervening change in clinical status or physical findings. In 
summary, there is no supportive evidence for the medical necessity of repeat TTE in this this enrollee's 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 echocardiography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an echocardiography, transthoracic, real-time with image documentation (2D), 
includes M-mode recording, when performed (93306).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D (82306), hemoglobin; glycosylated (A1C) 
(83036), prostate specific antigen (PSA); total (84153) and general health panel (80050) provided on August 8, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the Vitamin D, A1C, PSA and general health panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says these services are not covered OON. The 
Plan also says that code 80050 is not a covered code. 
 
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. 
Additionally, you have requested payment for services billed under code 80050. Medicare does not cover or 
pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for the 
Vitamin D (82306), hemoglobin; glycosylated (A1C) (83036), prostate specific antigen (PSA); total (84153) 
and general health panel (80050) provided on August 8, 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 office visit provided on March 16, 2023. 
 
You asked the Plan to pay for office visit. You say that you believe the services are medically necessary. 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 office visit provided on 
March 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 billed for date of service June 14, 
2022. 
 
You asked the Plan to pay for procedure code 95937. You say that this service is supported in the medical 
records. The Plan denied your request. The Plan says this service cannot be verified in the medical records 
provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 95937. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found the documentation does not contain evidence of 
neuromuscular junction testing. The record states that train of four testing was performed. Per coding 
guidelines, this is included in intraoperative neuromonitoring and is not separately reportable with 95937. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95937 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95937 billed for date of service June 14, 2022.