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

 
We decided that the Plan does not have to pay for chiropractic care provided on February 10, 2023. 
 
You asked the Plan to pay for chiropractic care. You say that you are appealing the claim payment denial. 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 chiropractic care 
provided on February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on 
May 24, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. You say that you disagree with 
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 $75 
copayment for outpatient diagnostic test/diagnosticprocedures and tests, includingultrasounds. 
 
You have been asked to pay a $75 copayment for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic test/diagnosticprocedures and tests, includingultrasounds 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 an outpatient diagnostic test provided on May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination provided on April 11, 2023. 
 
You asked the Plan to pay for radiologic examination. You say that this service is supported in the records. 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 radiologic examination 
provided on April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialist office visit provided on February 14, 2022. 
 
You asked the Plan to pay for the specialist office visit. You say that the Plan paid for other out-of-network 
visits. 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 the specialist office visit 
provided on February 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of extremity veins provided on May 19, 2023. 
 
You asked the Plan to pay for duplex scan of extremity veins. 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 duplex scan of extremity 
veins provided on May 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87798, and 87653 billed for date of 
service March 4, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87798, and 87653. You say that you disagree with the 
denial. The Plan denied your request. The Plan says payment for codes 87481, 87798, and 87653 is bundled 
into payment for code 87801. 
 
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 codes 
87481, 87798, and 87653 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. The -59 modifier is not supported as a separate and distinct procedural 
service. 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 87481, 87798, and 87653 billed for date of service March 4, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics, footplates, footplate cover, 
and backrest cover. 
 
You asked the Plan to pre-approve the upgraded electronics, footplates, footplate cover, and backrest cover. 
You say that the enrollee is eligible for a new power wheelchair due to its age. You say that the enrollee's 
current chair has issues. You also say that the enrollee was evaluated by a therapist which medically justifies 
why this power wheelchair is necessary for the enrollee. The Plan denied your request. The Plan says the code 
used for the footplates does not match the items requested. The Plan says that the back cover is already 
included with approved cushion. The Plan says that the footplate cover serves no medical purpose. The Plan 
also says that these accessories cannot be covered. 
 
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 upgraded electronics, footplates, 
footplate cover, and backrest cover. Our reviewer says that the requested upgraded electronics and backrest 
cover are not considered medically reasonable and necessary in this case. Our physician reviewer found the 
provided documentation indicates the enrollee has sufficient strength and function in upper extremities to 
manage standard power drives. The reviewer found that the guidelines indicate that the requested back cover is 
covered with the approved cushion. Therefore, the reviewer found that the upgraded electronics and backrest 
cover are 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 the upgraded electronics and backrest cover have not been met. Additionally, 
there is no medical need for the requested footplates and covers. Therefore, we decided that the Plan does not 
have to pre-approve the upgraded electronics, footplates, footplate cover, and backrest cover.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 15, 2021. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until March 22, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on March 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on  
April 13, 2023. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that his client has out-f-network 
benefits through a Medicare Advantage policy and this claim should be paid. The Plan denied your request. 
The Plan says Licensed Professional Counselors are not currently eligible providers to received payment for 
mental health services under the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor 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 Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation 
provided on April 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for walking boot provided on March 06, 2023. 
 
You asked the Plan to waive the coinsurance for walking boot. You say that you do not agree with the cost 
share. 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 prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for walking boot. This item/service falls within the prosthetic 
devices 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. The total you owe is $69.28 ($346.41 allowed amount x 20% = $69.28) Therefore, we 
decided that the Plan does not have to waive the coinsurance for walking boot provided on March 06, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve i-FACTOR allograft and bone marrow aspirate (22853, 
20939). 
 
You asked the Plan to pre-approve i-FACTOR allograft and bone marrow aspirate. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not 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 pre-approve i-FACTOR allograft and bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found no compelling rationale is presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
bone marrow aspirate and i-FACTOR allograft are not medically reasonable or 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 i-FACTOR allograft and bone marrow aspirate have not been met. Therefore, 
we decided that the Plan does not have to pre-approve i-FACTOR allograft and bone marrow aspirate (22853, 
20939).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (U0004, U0005) provided September 
1, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that these codes come under the Public Health 
Emergency extension. Please check the attachments and consider and process the claim accordingly. The Plan 
denied your request. The Plan says the claim was received after the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory service was not filed until April 20, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory service (U0004, U0005) provided September 1, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for these services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific 
and effective for the enrollee's condition. The records do not demonstrate that the unique skills of a 
professional therapist are required to safely and effectively provide treatment, that services can be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist. The requested services 
are not part of a maintenance program. The enrollee and caregiver have had extensive training. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy (PT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 7, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you want us to reconsider our decision. The Plan 
denied your request. The Plan says you must use network providers. if you receive unauthorized care from an 
out-of-network provider, they may deny coverage and you will be responsible for the entire cost. 
 
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 April 7, 2023, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Osteocel allograft. 
 
You asked the Plan to pre-approve the allograft. You say that the requested allograft is medically necessary. 
The Plan denied your request. The Plan says the allograft 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 an Osteocel allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that an Osteocel allograft is experimental in spinal surgery when used as bone graft. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Osteocel allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Osteocel allograft.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx panel provided on April 25, 
2023. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx panel. You say that this testing was medically 
necessary.  The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of this 
testing. 
 
The Plan must follow Medicare rules. Medicare rules say that this testing is covered when the enrollee has 
either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. In this case the record does not show that the enrollee has either 
recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. Based on this information, we 
decided that Medicare rules for coverage of the FoundationOne Liquid CDx panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the FoundationOne Liquid CDx panel provided on 
April 25, 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 26, 2023, to 
April 24, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you 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 26, 2023, to April 
24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) October 14, 2022, 
to November 4, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with this denial and 
believe these services were medically necessary. 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 follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) October 14, 2022, to November 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AAA screening provided on May 23, 2023. 
 
You asked the Plan to pay for the AAA screening. You say that you needed to have this service done to see if 
the aneurysm was stable and if it had grown. The Plan denied your request. The Plan says your benefit for a 
AAA screening has already been exhausted. 
 
The Plan contract also says that a one-time AAA screening ultrasound is covered for people at risk. 
 
The record shows you received a AAA screening on January 18, 2018. Therefore, your benefit for this service 
has been exhausted. We decided that the Plan does not have to pay for the AAA screening provided on May 23, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on May 12, 2023. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting medical records. 
The Plan denied your request. The Plan says the records do not include an order that specifically lists what tests 
were to be performed in this panel. 
 The Plan must follow Medicare rules. Medicare rules say that all diagnostic laboratory tests must be 
specifically ordered by the physician that is treating the beneficiary.  
 
We looked at the file and Medicare rules. Although the record includes an order for a proprietary test panel, the 
order does not note the specific tests included in this panel testing to support the tests performed or the codes 
billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug testing 
have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on May 
12, 2023.