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

 
We decided that the Plan does not have to waive the coinsurance for the gastric device removal provided on 
October 26, 2020. 
 
You asked the Plan to waive the coinsurance for the gastric device removal. You say that this was a medically 
necessary procedure. 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 4% 
coinsurance for out-of-network outpatient surgery. 
 
You have been asked to pay 4% coinsurance for the gastric device removal. This item/service falls within the 
out-of-network outpatient surgery 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. The total you owe is $117.55 ($2,938.73 allowed amount x 4% coinsurance = 
$117.55). Therefore, we decided that the Plan does not have to waive the coinsurance for the gastric device 
removal provided on October 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and accessory to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compression device and accessory. You say that no other 
supplier can provider the unique equipment needed. The Plan denied your request. The Plan says this is 
available in-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 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 provider at issue in this case is not a network provider with the Plan. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pre-approve a pneumatic compression device and accessory. Our reviewer says that the 
Plan has in-network providers who meet the standards of care required for the treatment of the enrollee's 
condition. Our physician reviewer found there is nothing unique with the enrollee's condition or clinical 
situation that would suggest the in-network device would not be sufficient for her needs. There was no failed 
trial of the covered device offered by the plan or contraindication to such to justify this request for a dual wave 
mode pump system. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a pneumatic compression device and accessory have not been met.  
 
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 a pneumatic compression device and accessory. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device and 
accessory to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on January 
25, 2023. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that this should be included in 
the 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 $10 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $10 copayment for the laboratory services. This item/service falls within the 
specialist physician/practitioner 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. The records show you are being asked to pay a single office visit copayment 
for this date of service. Therefore, we decided that the Plan does not have to waive the copayment for the 
laboratory services provided on January 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 21, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for laboratory services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the service 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 laboratory services provided on February 21, 
2023, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99308) provided on January 26, 2023 to 
March 16, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 CPT code 99308 is not supported in the medical record. Specifically, diagnosis codes , I73.9 
(Peripheral vascular disease, unspecified) and I70.234 (Atherosclerosis of native arteries of right leg with 
ulceration of heel and midfoot) have an exclude note and cannot be billed together. Based on this information, 
we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99308) provided on January 26, 2023 to 
March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the group 1 standard power operated vehicle (K0800) 
purchased on October 27, 2022, from a non-Medicare certified provider. 
 
You asked the Plan to pay for the group 1 standard power operated vehicle. You say that the distance you 
would have to travel to get to the in-network store would be a hardship for you. You also say that your medical 
conditions meet the requirements for a standard power operated vehicle, and you should be eligible for 
reimbursement. The Plan denied your request. The Plan says you purchased the durable medical equipment 
(DME) directly from a non-certified supplier. The Plan also says that Medicare and the Plan will only cover the 
DME from approved certified suppliers. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the group 1 standard power operated 
vehicle (K0800) purchased on October 27, 2022, from a non-Medicare certified provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
February 28, 2023, to March 02, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were told you were 
not an inpatient. 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 $200 
copayment for in-network inpatient hospital care. 
 
You have been asked to pay a $200 copayment for the inpatient hospital stay. This item/service falls within the 
in-network 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. The medical records show you were admitted as an inpatient. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on February 
28, 2023, to March 02, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 11, 2023 to 
April 9, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
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 March 11, 2023 to April 
9, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on March 09, 2023. 
 
You asked the Plan to pay for an ultrasound. You say that the enrollee had another insurance when the referral 
was made and the initial appointment had to be rescheduled. 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 ultrasound provided 
on March 09, 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 
November 3, 2022.  
 
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 November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine GYN exam provided on April 4, 2023. 
 
You asked the Plan to pay for the routine GYN exam. You say that you were not aware that this benefit could 
only be covered once every 24 months after age 65. The Plan denied your request. The Plan says you have 
exceeded the benefit limit. 
 
The Plan contract covers cervical and vaginal cancer screening once every 24 months. 
 
We looked at the file and the Plans rules. The file shows that the Plan covers cervical and vaginal cancer 
screening once every 24 months. Based on this information, we decided that the Plans rules for coverage of 
the routine GYN exam have not been met. Therefore, we decided that the Plan does not have to pay for a 
routine GYN exam provided on April 4, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 6, 2022, to 
January 4, 2023. 
 You asked the Plan to pay for the home health services. You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 6, 2022. The NOA was not received by the Plan until February 
28, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from December 6, 2022, to January 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit and lesion destruction provided on March 20, 
2023. 
 
You asked the Plan to pay for a home visit and lesion destruction. You say that the service was 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 a home visit and lesion 
destruction provided on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block and RFA. 
 
You asked the Plan to pre-approve a genicular nerve block and RFA. You say that a genicular nerve block and 
RFA is medically necessary. The Plan denied your request. The Plan says the requested genicular nerve block 
and RFA is experimental, investigational and 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 a genicular nerve block and RFA. Our 
reviewer says that the requested genicular nerve block and RFA is not considered medically reasonable and 
necessary. Our physician reviewer found that the role of genicular nerve blocks and of RFA of the genicular 
nerves after a total knee replacement is the subject of an ongoing clinical trial and is considered experimental at 
this time. Therefore, the request is deemed not medically reasonable and 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 a genicular nerve block and RFA have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a genicular nerve block and RFA.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral breast surgery. 
 
You asked the Plan to pre-approve a bilateral breast surgery. You say that your skin constantly has an odor, and 
you have regular infections. The Plan denied your request. The Plan says this surgery appears to be cosmetic in 
nature. 
 
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 a bilateral breast surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record as provided is insufficient to support the medical necessity of the 
requested service. The record provided does not establish the medical necessity and reasonableness, as defined 
by Medicare rules, of the requested service.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bilateral breast surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bilateral breast surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 9, 2023, billed 
with procedure code 93005. 
 
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 that payment for this service was included in the 
primary procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the practitioner services provided have not been met. Procedure code 93005 has a Q1 status 
modifier and was billed on the same claim as code 99285 which has a status indicator V. Therefore, we decided 
that the Plan does not have to pay for practitioner services provided on February 9, 2023, billed with procedure 
code 93005.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 17, 2022, to 
March 1, 2022. 
 You asked the Plan to pay for the home health services. You say that You did not provide a specific argument 
with your appeal request. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 17, 2022. The NOA was not received by the Plan until April 4, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 17, 2022, to March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on February 21, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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 provided on February 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 23, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services.  The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
23, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that this service is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Hyalgan. Our reviewer says that 
Hyalgan is not medically necessary. Our physician reviewer found there is no documentation indicating that the 
enrollee has failed physical therapy, non-narcotic pain medications, aspiration of the knee, and/or steroid 
injections. A trial of conservative therapy is required before this injection can be considered 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.