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

 
We decided that the Plan does not have to pre-approve a nerve stimulator (64555). 
 
You asked the Plan to pre-approve the nerve stimulator. 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. 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 nerve stimulator. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of peripheral nerve stimulation for the treatment of chronic knee pain is considered 
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 nerve stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a nerve stimulator (64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the telehealth visit provided by an out-of-
network provider on August 23, 2023. 
 
You asked the Plan to waive the deductible for the telehealth visit. You say that this is an in-network provider. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,500 deductible which applies to out-of-network 
physician/practitioner services, including doctors office visits. 
 
 
 
 
 
 You have been asked to pay a $104.42 deductible for the telehealth visit. The item or service you asked the 
Plan to waive the deductible for was provided by an out-of-network provider. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $1,500 deductible which applies to out-of-network 
physician/practitioner services, including doctors office visits. This cost sharing is a contractual obligation that 
had not been met at the time the telehealth visit was provided on August 23, 2023. Therefore, we decided that 
the Plan does not have to waive the deductible for the telehealth visit provided by an out-of-network provider 
on August 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on July 1, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you do not agree with the denial of payment, 
we have sent all the appropriate documents. The Plan denied your request. The Plan says you are not enrolled 
in Medicare as a durable medical equipment supplier. Therefore, the claim was denied. 
 
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 you are not enrolled in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided on July 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight wheelchair (K0005) and related 
accessories. 
 
You asked the Plan to pre-approve an ultralightweight wheelchair and related accessories. You say that the 
requested items are a necessity for your care. The Plan denied your request. The Plan says rules for coverage 
for durable medical equipment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve an ultralightweight wheelchair (K0005) and related accessories.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
July 12, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you shouldnt have 
to pay the amount. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for emergency care. 
 
You have been asked to pay a $120 copayment for the emergency room services. This item/service falls within 
the emergency care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room 
services provided on July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that this bed is medically necessary. 
The Plan denied your request. The Plan says this item is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on October 05, 2023. 
 
You asked the Plan to pay for a home visit evaluation. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit evaluation 
provided on October 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dialysis procedures to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the dialysis procedures. You say that you are requesting reconsideration of 
the denied services. The Plan denied your request. The Plan says the services were not approved. 
 
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 
the dialysis procedures to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthesis. 
 
You asked the Plan to pre-approve the prosthesis. You say that this equipment is medically necessary. The Plan 
denied your request. The Plan says there are network providers available in your service area. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The Plan says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from your home who can provide the prosthesis. Under Medicare rules, this means that contract providers are accessible to you. Therefore, we decided that the Plan does not 
have to pre-approve a prosthesis.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transthoracic echocardiogram (TTE) 
provided on September 27, 2023. 
 
You asked the Plan to waive the copayment for a transthoracic echocardiogram (TTE). You say that you were 
not aware of 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 $110 
copayment for in-network Medicare-covered radiological diagnostic services, including ultrasounds. 
 
You have been asked to pay a $110 copayment for a transthoracic echocardiogram (TTE). This item/service falls within the in-network Medicare-covered radiological diagnostic services, including ultrasounds 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 a transthoracic echocardiogram (TTE) provided 
on September 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided on 
August 11, 2023, to August 13, 2023. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you should only be 
charged for one day. 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 inpatient hospital care. 
 
You have been asked to pay a $325 copayment for the inpatient hospital stay. This item/service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. You have been asked to pay a total of $650 for the inpatient hospital stay ($325 copayment 
x 2 days = $650). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to reduce the copayment for the inpatient hospital stay provided on August 11, 2023, to 
August 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient stays provided from May 3, 
2023, to May 5, 2023, and May 6, 2023, to May 16, 2023. 
 
You asked the Plan to waive the copayment for the hospital stays. You said that you wanted to appeal 
copayment amounts for your inpatient stay. 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 $350 
copayment for days 1 to 5 for Medicare-covered inpatient hospital care each time you are admitted. There is a 
$0 copayment for additional Medicare-covered days.  You have been asked to pay $700, which is a $350 copayment for days 1-2 of the inpatient stay from May 3, 
2023, to May 5, 2023 ($350 copayment x 2 days = $700). You were not charged for the day you were 
discharged. 
 
You have also been asked to pay $1,750, which is a $350 copayment for days 1-5 of the inpatient stay from 
May 6, 2023, to May 16, 2023 ($350 copayment x 5 days = $1,750). You have not been charged beyond day 
five. You have been asked to pay a total of $2,450 ($700 copayment + $1,750 copayment = $2,450). These 
services fall within the inpatient hospital care 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 copayment for the inpatient stays provided from May 3, 2023, to May 5, 2023, and May 6, 2023, to May 
16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on July 
12, 2023, to July 19, 2023. 
 
You asked the Plan to pay for the skilled nursing facility (SNF) services. You say that it is the nursing facilities 
responsibility to get authorizations for their patients. 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 skilled nursing 
facility (SNF) services provided on July 12, 2023, to July 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on July 22, 2023. 
 
You asked the Plan to pay for genetic testing. You say that this testing 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 genetic testing provided 
on July 22, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99291 billed for date of service August 14, 2023. 
 
You asked the Plan to pay for code 99291. You say that modifier 24 was appended to this code to show that it 
was an unrelated service. Code 99291 should be paid separately. The Plan denied your request. The Plan says 
that code 99291 was billed on the same day as a procedure that has a global surgical period (i.e., code 36556). 
Code 99291 us included when billed on the same day as 36556 without an appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that the global surgery package includes all additional 
medical services required of the surgeon during the postoperative period. In order to report an unrelated 
evaluation and management (EM) service by same physician during a postoperative period, modifier -24 must 
be used. Services submitted with the -24 modifier must be sufficiently documented to establish that the visit 
was unrelated to the surgery. 
 
In this case, the Plan's reason for denial does is not supported.  The Plan's sole rationale for denial is that code 
99291 is considered part of the global package for code 36556 because it was it was not billed with a modifier 
to indicate it was a separate service.  This is not true.  The claim records and your appeal request clearly 
document that code 99291 was billed with the 24 modifier.  This modifier indicates that the EM service was 
distinct and separate from the surgery itself.  The Plan has set forth no argument that the 24 modifier was 
appended inappropriately or not supported by the medical record. By failing to address the presence of this 
modifier on the claim, we find that the Plan's denial is not supported. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99291 have been met. Therefore, we decided that the Plan has to pay for code 99291 billed 
for date of service August 14, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tempus xR testing. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing tests must have Food 
and Drug Administration (FDA) approval. 
 
We looked at the file and Medicare rules. The requested test is not approved by the FDA. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Tempus xR testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 22, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
August 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
March 29, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford 
the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $245 
copayment for you cannot afford the copayment.. 
 
You have been asked to pay a $245 copayment for the ambulance transportation. This item/service falls within 
the you cannot afford the copayment. benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the ambulance transportation provided on March 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bathtub wall rail (a grab bar). 
 
You asked the Plan to pre-approve a grab bar. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested item is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a bathtub wall rail (a grab bar).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC testing (0315U) provided on August 
17, 2023. 
 
You asked the Plan to pay for the DecisionDx-SCC testing. You say that this testing is medically necessary.  
The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC testing (0315U) provided on 
August 17, 2023.