Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that you do not agree with the denial of payment. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on November 22, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider must attempt to consult the attending or primary care physician 
about the services furnished and document the consent or declination date to consultations, and the date of 
consultations in the patients medical record. There was no documentation of contact in the patient record.  
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this is supported in the records. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 an office visit provided on September 26, 2022, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital care. 
 
You asked the Plan to pre-approve continued inpatient psychiatric hospital care. You say that you are still an 
imminent danger to others as you are refusing medication, being noncompliant with treatment, verbally 
aggressive, and among other things for which you need 24-hour supervision under physician care. The Plan 
denied your request. The Plan says the request for inpatient behavioral health level of care for this admission is 
not medically necessary. The service you need can be provided safely in other settings. The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric hospital 
care. Our reviewer says that the service is not medically necessary. Our physician reviewer found based upon 
review the records provided it was not expected that you would improve in a reasonable period of time for the 
dates in question as you did not have suicidal or homicidal ideation, auditory or visual hallucinations. You were 
compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary 
and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of 
care beyond the dates in question as you did not have dangerousness to self or others and was compliant with 
your treatment. The health plans denial of continued inpatient psychiatric services is appropriate. You did not 
appear to require inpatient mental health treatment beyond the date in question as you were not a danger to 
herself or others and does not have auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services were reasonably expected to 
improve your condition or for the purpose of diagnosis beyond the date in question. You were treated under an 
individualized treatment plan found in the record. It did appear that the records were supervised and evaluated 
by a physician. Based upon review, the records provided for your admission does not meet the criteria for May 
17, 2023, forward as you were not shown to be a danger to yourself or others, delusions, auditory or visual 
hallucinations noted. You were cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric hospital care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); 
gastrointestinal pathogen (87507) provided October 11, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denial, review of the medical records and approval of the services provided. The Plan denied your request. The 
Plan says the records do not support that the Medicare criteria for coverage has been met. 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that the test at issue 
in this case meets all Medicare criteria for medically reasonable and necessary for the enrollee. The provided 
medical records in this case consist of the test requisition with a cited diagnosis of unspecified diarrhea and the 
test results. Records do not include any clinical history, examination, other results or evaluation and 
management notation indicating necessity of the test (or necessity of the test as opposed to a standard stool 
culture or stool assay for Clostridium Difficile toxin). 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen 
(87507) provided October 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma test (81529) provided on 
November 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that the DecisionDx-Melanoma test was denied in error, 
and you are requesting it be reprocessed and paid. The Plan denied your request. The Plan says non-emergent 
services with non-contracted providers require prior authorization before 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. Genetic testing is listed on the Prior Authorization Reference Chart on page 64 of the 
EOC. 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 the DecisionDx-Melanoma test (81529) provided on November 
10, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from June 23, 2022, to  
December 7, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that this provider has worked with you for years. You 
say these were individual talk therapy sessions in the office with only the two of you present and you have 
found her to be extremely helpful. The Plan denied your request. The Plan says Medicare does not cover 
marriage and family therapist services. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program.  
Therefore, we decided that the Plan does not have to pay for psychotherapy provided from June 23, 2022, to 
December 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 5, 2022, to 
January 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the NOA. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 5, 2022, to 
January 10, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychotherapy provided on October 31, 2022. 
 
You asked the Plan to reimburse you for psychotherapy. The Plan denied your request. The Plan says this 
provider is not part of the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program.  
Therefore, we decided that the Plan does not have to reimburse you for psychotherapy provided on  
October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service January 23, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service January 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Monitor test (0013M) provided on June 30, 
2022. 
 
You asked the Plan to pay for the Cxbladder Monitor test. You say that this service 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 Monitor test have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cxbladder Monitor test (0013M) provided on June 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on November 1, 2022, to 
December 13, 2022, by out-of-network (OON) providers. 
 You asked the Plan to pay for the wound care supplies. You say that you were not told by anyone where you 
could obtain these supplies. The Plan denied your request. The Plan says these supplies are not covered when 
purchased from an out-of-network provider. 
 
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 providers in this case are not network providers 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 items at 
issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the 
Plan does not have to pay for the wound care supplies provided on November 1, 2022, to December 13, 2022, 
by out-of-network (OON) providers.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmic ultrasound provided on October 10, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmic ultrasound. You say that you have never had an enrollee with an 
HMO requiring prior authorization. You say you were under the impression that the enrollee was eligible to 
any provider due to their Medicare/Medicaid status. The Plan denied your request. The Plan says there is no 
prior authorization, and the provider was out-of-network. 
 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 did not pre-approve the 
ophthalmic ultrasound. We found no exception that would require the Plan to pay for the ophthalmic 
ultrasound. Therefore, we decided that the Plan does not have to pay for the ophthalmic ultrasound provided on 
October 10, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A0425 billed for date of service August 20, 2022. 
 
You asked the Plan to pay for code A0425. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed for one line.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service on 
one line exceeds the MUE value cannot be paid when the MAI value is 1.  
 
In this case, the MUE for code A0425 is 250. The MAI value for this code is 1. You billed 285 units of this 
code on one line, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage 
of code A0425 have not been met. Therefore, we decided that the Plan does not have to pay for code A0425 
billed for date of service August 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON second opinion. You say that you want someone outside of the 
system to look at your hand and the images to see if there is any nerve damage from surgery that is causing the 
fingers to not respond to brain requested moving orders. You say that you want someone outside of the system 
to look at your hand and the images to see if there is shortening of the tendon from surgery that would cause 
the middle and ring finger to not be able to function and bend properly, making them stay in an open and 
locked position. The Plan denied your request. The Plan says there are equally qualified network providers who 
you have not yet seen available to provide a second opinion. 
 
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 
a second opinion to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 62322 and 99100 billed for date of service 
November 28, 2022. 
 
You asked the Plan to pay for procedure codes 62322 and 99100. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for code 62322 is bundled into payment for code 
01360. Code 99100 is 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 CPT code. In this case, we have confirmed that code 62322 
is a column II code to column I code 01360. This claim has not been billed with an appropriate modifier to 
bypass the edit. We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. 
This means that procedure code 99100 is not separately payable. 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 
62322 and 99100 billed for date of service November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Naprapathic manipulation services provided on January 
31, 2022, and February 21, 2022. 
 
You asked the Plan to pay for the Naprapathic manipulation services. You say that the Plan is unable to specify 
what they consider to be Naturopathic treatment. You also say that you believe the treatments you received 
qualify under the category of Naturopathy. The Plan denied your request. The Plan says the treating provider is 
a Doctor of Naprapathy and is not a licensed Doctor of Naturopathy. 
 
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 do not show any evidence that the treating provider is participating 
with Medicare. The Plan contract also does not include coverage specifically for Naprapathic providers under 
the Wellness Wallet benefit. Therefore, we decided that the Plan does not have to pay for the Naprapathic 
manipulation services provided on January 31, 2022, and February 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
September 24, 2022. 
 You asked the Plan to pay for the hospital discharge day management. You say that per hospice denial, charges 
are prior to enrollee being discharged from the hospital, and prior to hospice admission. You also say that you 
would like this reprocessed. 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 the hospital discharge day management (99239) provided on 
September 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0650) and pneumatic 
appliances (E0673, E0655) and orthotics management and training (97760) provided on December 7, 2021. 
 
You asked the Plan to pay for the pneumatic compression device, appliances and orthotics management. You 
say that you are appealing the denial of your equipment as not medically necessary for outpatient use following 
surgery. The Plan denied your request. The Plan says pneumatic compression device is not covered by 
Medicare to prevent deep vein thrombosis during and/or following surgery.  
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (E0650) and pneumatic appliances (E0673, E0655) and 
orthotics management and training (97760) provided on December 7, 2021.