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

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on 
July 13, 2022 
 
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 chiropractic manipulative treatment 
provided was not medically necessary.  
 
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.  
 
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 pay for this service. Our reviewer says that the 
chiropractic manipulative treatment provided was not medically necessary. Our physician reviewer found that 
in this case, the record indicates that you have chronic pain sources including the shoulders, pelvis, and back.  
  
 
The records provided do not document the presence of a subluxation of the spine either by physical 
examination or radiographic images. The elements of the coverage criteria are not satisfied.    
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for the chiropractic manipulative treatment (98941) provided on July 13, 2022
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit for the evaluation and 
management of an established patient (99335) provided on December 2, 2022, by an out-of-network (OON) 
provider.  
 You asked the Plan to pay for domiciliary or rest home visit for the evaluation and management of an 
established patient. You say that the providers rely on facility staff to verify eligibility and obtain authorization 
from the insurance company. The Plan denied your request. The Plan says authorization was not obtained prior 
to the services being 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 domiciliary or rest home visit for the evaluation 
and management of an established patient (99335) provided on December 2, 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 home infusion therapy services provided on November 17, 
2022, to November 18, 2022. 
 
You asked the Plan to pay for home infusion therapy services. You say that you think that these services 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 home infusion therapy 
services provided on November 17, 2022, to November 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on January 26, 2023. 
 
You asked the Plan to pay for eye refraction. You say that your eye felt strange. The Plan denied your request. 
The Plan says this service is only covered when performed by a Plan routine vision care provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed by a Plan routine vision care provider. 
 
We looked at the file and the Plan's rules. This service was not performed by a Plan routine vision care 
provider. Based on this information, we decided that the Plan's rules for coverage of eye refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on January 
26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service 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 the intracept procedure. Our reviewer 
says that the requested service i not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the cause of back pain is unclear. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (64628).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0210, D0150 and D7210) on January 
28, 2023. 
 
You asked the Plan to pay for the dental services (D0210, D0150 and D7210). You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. The requested service (D7210) was denied as it was 
determined that service (D7140) can be performed as an alternative benefit. 
 
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, certain limitations apply. The record shows your benefit for the requested item or service was exhausted on date of service December 10, 2020 
(D0150 and D0210). Therefore, we decided that the Plan does not have to pay for the dental services (D0210, 
D0150 and D7210) on January 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on February 03, 2023. 
 
You asked the Plan to pay for injections. You say that the services were 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 injections provided on 
February 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wheelchair provided from November 
16, 2022, to February 16, 2023 
 
You asked the Plan to waive the coinsurance for the wheelchair. You say that you did not receive this 
wheelchair 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 2022 contract with the Plan clearly says that you must pay 
20% coinsurance for in-network durable medical equipment and related supplies. Your 2023 contract with the 
Plan also clearly says you must pay 20% coinsurance for in-network durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance each month for the wheelchair. This item/service falls within the 
durable medical equipment and related 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 the wheelchair provided from November 16, 2022, to February 16, 2023
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MI Profile and MI Tumor Seek genetic testing. 
 
You asked the Plan to pre-approve genetic testing. You say that the testing will analyze actionable biomarkers 
resulting in therapy response associations based on extensive evidence review. The Plan denied your request. 
The Plan says the requested testing is not approved by the Food & Drug Administration (FDA). 
 
The Plan must follow Medicare rules. Medicare rules say that NGS as a diagnostic laboratory test is reasonable 
and necessary and covered nationally, when performed in a CLIA certified laboratory, when ordered by a 
treating physician, and when all the requirements are met 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, the requested testing is not FDA approved. 
Therefore, we decided that the Plan does not have to pre-approve MI Profile and MI Tumor Seek genetic 
testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service December 9, 
2022. 
  You asked the Plan to pay for procedure code 36000. You say that the enrollee was seen by the emergency 
room physician for a medically necessary procedure and the claim should be reprocessed to pay this procedure 
code. The Plan denied your request. The Plan says procedure code 36000 is considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service December 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vertiflex device placement surgry. 
 
You asked the Plan to pre-approve the vertiflex device placement surgery. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this procedure is considered experimental. 
 
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 the vertiflex device placement surgery. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case.  Our physician reviewer found the vertiflex device is experimental. 
 
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 vertiflex device placement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the vertiflex device placement surgry.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99318 billed for date of service September 
16, 2022. 
 
You asked the Plan to pay for the billed services . You say that medically necessary services were provided in 
good faith.  The Plan denied your request. The Plan says the rules for payment have not been met.  
 
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 99318 is evaluation and management of a patient 
involving an annual nursing facility assessment.  
 We find that CPT code 99318 is not supported. CPT code 99318 was billed and paid for date of service 
February 7, 2022. This annual service is not payable more than once per year. 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 procedure code 99318 billed for date of service September 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 25, 
2022, to December 26, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary.  The Plan denied your request. The Plan says that an inpatient level of care was not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case.  Our 
physician reviewer found that the review indicates that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that your necessary hospital care, including emergency 
care and/or observation care, would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from December 25, 2022, to December 
26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the request is not medically necessary because the records do not show that 
they are expected to improve a lot in a reasonable amount of time and that they need an intensive team. The 
services they need can be provided safely 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.  Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
and ground mileage provided on September 10, 2022. 
 
You asked the Plan to pay for the ambulance services and ground mileage. You say that you are asking for 
reconsideration of the claim for payment and are seeking for review. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 25, 2022. The services in question were provided 
before the end of that month.  Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, emergency transport and ground mileage provided on September 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection provided on December 30, 
2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were told this service was 
covered at 100%. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the injection. This item/service falls within the Medicare Part 
B prescription 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. Therefore, we decided that the Plan does not have to waive the coinsurance for the injection 
provided on December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the drug administration services provided 
from January 1, 2022, to April 25, 2022. 
 
You asked the Plan to waive the copayments for the drug administration services. You say that this is a simple 
injection, you should only have a specialist office visit 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 $325 
copayment for in-network outpatient hospital visits.  
 
The record shows the Plan initially processed the claim incorrectly and it was sent back for reprocessing. You 
have been asked to pay a $194.59 copayment for each visit, which is less than the standard $325 copayment for the drug administration services. These items/services fall within the outpatient hospital services 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 the drug administration services provided from 
January 1, 2022, to April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the image guided radiation therapy (IGRT) (77399). 
 
You asked the Plan to pre-approve radiation therapy. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says IGRT is not considered 
medically necessary and does not meet the Plan's criteria. 
 
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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that IGRT is not the standard of care for the skin cancer removal in this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the image guided radiation therapy (IGRT) (77399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM. 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this request is for weight loss. The Plan 
denied your request. The Plan says the enrollee does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia. Based on this information, we decided that 
Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a therapeutic CGM.