Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0220) provided on April 
6, 2022. 
 
You asked the Plan to pay for the dental service. You say that you never asked for the x-ray, and you would 
like to be refunded the amount that you paid for it. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the intraoral radiographic image is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral radiographic image (D0220) provided on April 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance services (A0428, A0425) to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve non-emergency ambulance services with an out-of-network provider. You 
say that the services are necessary. The Plan denied your request. The Plan says this provider is out-of-network. 
These services are 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 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 
non-emergency ambulance services (A0428, A0425) 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 the hospital outpatient clinic visit (G0463) provided on June 
1, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient visit. You say that the service was medically necessary. You also 
say this should be reprocessed and paid. The Plan denied your request. The Plan says prior authorization was 
not obtained. 
 
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 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 the hospital outpatient clinic visit (G0463) 
provided on June 1, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service May 22, 2023. 
 
You asked the Plan to pay for the billed services. You say that the results of test impact clinical decisions. 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. The test was reviewed by MolDX and was found to not demonstrate 
clinical utility at a level that meets the Medicare reasonable and necessary requirement. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for the lab testing billed for date of service May 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ligation or banding of angioaccess arteriovenous fistula 
(37607) provided on April 20, 2023, with an assistant surgeon. 
 
You asked the Plan to pay for the surgical service. You say that this service is listed as covered. You also say 
that it is not listed on the MCR exclusion list. The Plan denied your request. The Plan says the claim processed 
correctly. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 37607. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgical service have not been met. Therefore, we decided that the Plan does not have to pay for the ligation or 
banding of angioaccess arteriovenous fistula (37607) provided on April 20, 2023, with an assistant surgeon.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the prolonged office visit provided on May 17, 2023. We decided 
that the Plan does not have to pay for the prolonged office visit provided from March 20, 2023, to April 17, 
2023.  
 
You asked the Plan to pay for the prolonged office visits provided from March 20, 2023, to May 17, 2023. You 
say that the enrollee received these exact services in the past and they were covered. You say that the services 
are not being covered the same way now. You also say that they should be. The Plan says that the providers in 
this case have opted out of Medicare. The Plan also says that payment cannot be made for services performed 
by a provider that has opted out of Medicare. 
 
We decided that the Plan has to pay for the prolonged office visit provided on May 17, 2023.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file indicates a different rendering provider for the services on 
May 17, 2023. The file does not support that the rendering provider for this date of service has opted out of 
Medicare. It is not reasonable for the enrollee to know how the services would be billed. Therefore, we decided 
that the Plan has to pay for the prolonged office visit provided on May 17, 2023.  
 
We also decided that the Plan does not have to pay for the prolonged office visit provided from March 
20, 2023, to April 17, 2023. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue from March 20, 2023, to April 17, 2023, were provided in a non-urgent, non-emergent 
situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does 
not have to pay for the prolonged office visit provided from March 20, 2023, to April 17, 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 pay for the genetic testing provided on March 1, 2023, billed with 
codes 87481, 87641, 87798, 87640, 87500, 87651, 87471, 87493, 87529, 87563, and 87653. 
 
You asked the Plan to pay for the testing billed. You say that the codes are approved by Medicare. The Plan 
denied your request. The Plan says the codes are not supported.  
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
The file shows that a wound panel was ordered. We looked at the file and Medicare rules. This NGS panel was 
not billed with a single code as required. The medical records do not show that the services billed with the -59 
modifier were distinct procedural services. Based on this information, we decided that Medicare rules for 
coverage of the testing billed have not been met. Therefore, we decided that the Plan does not have to pay for 
the genetic testing provided on March 1, 2023, billed with codes 87481, 87641, 87798, 87640, 87500, 87651, 
87471, 87493, 87529, 87563, and 87653.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health assessment (H0031), mental health service 
plan development (H0032), psychosocial rehabilitation services (H2017), therapeutic behavioral services 
(H2019). 
 
You asked the Plan to pay for the mental health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says these services are not approved for telehealth. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of a telecommunications system may 
substitute for an in-person encounter for professional consultations, office visits, office psychiatry services, and 
a limited number of other physician fee schedule (PFS) services. The various services and corresponding 
current procedure terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes are listed on the CMS website.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the mental health services have not been met. Therefore, we decided that the Plan does not have to 
pay for the mental health assessment (H0031), mental health service plan development (H0032), psychosocial 
rehabilitation services (H2017), therapeutic behavioral services (H2019).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH admission is the appropriate 
level of care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the 
LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. Given there are offered alternatives, LTACH is not 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid circulating cold pad with pump (E0218) provided on 
March 19, 2023, through April 7, 2023. 
 
You asked the Plan to pay for a fluid circulating cold pad with pump. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does 
not have to pay for a fluid circulating cold pad with pump (E0218) provided on March 19, 2023, through April 
7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on May 19, 2023.  
 
You asked the Plan to pay for foot orthotics. You say that you would like reconsideration because the requested 
foot orthotics are medically necessary. 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 provided on May 19, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says an epidural 
steroid injection is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that an 
epidural steroid injection is not medically necessary. Our physician reviewer found that the enrollee has had 4 
injections within a 12-month period. Also, it is not clear from the documentation that the enrollee is getting 
50% pain relief for three months. Therefore, the request is 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires extensive physical and 
occupational therapy services to regain their independence. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall significantly complies with the various documentation requirements for IRF 
admission. The enrollee's condition is complex and fragile, and there is every reason to expect that they will 
participate in and benefit from IRF services to include at minimum physical and occupational therapy, careful 
physician oversight of polypharmacy, and case manager coordination of any additional services that might be 
needed to make a sustainable return home, as well as avoid preventable readmissions to the acute hospital. 
Therefore, the requested inpatient rehabilitation facility admission is approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each outpatient hospital service provided 
on March 17, 2023, to April 13, 2023. 
 
You asked the Plan to waive the copayment for each outpatient hospital service. You say that you think that 
you were billed incorrectly. 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 $340 
copayment for in-network Medicare-covered outpatient hospital observation services. 
 
You have been asked to pay a $340 copayment for each outpatient hospital service. This item/service falls 
within the in-network Medicare-covered outpatient hospital observation 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 total amount you owe is $680 
($340 copayment x 2 services = $680). Therefore, we decided that the Plan does not have to waive the 
copayment for each outpatient hospital service provided on March 17, 2023, to April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and laboratory service provided on July 26, 
2023, by an OON provider.  
 
You asked the Plan to pay for the office visit and laboratory service. You say that you are requesting 
reconsideration of the denied claim. 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 the office visit and laboratory service provided on 
July 26, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for s fluid circulating cold pad with pump (E0218), provided on 
February 16, 2023, through March 7, 2023. 
 
You asked the Plan to pay for a fluid circulating cold pad with pump . You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump  have not been met. Therefore, we decided that the Plan 
does not have to pay for s fluid circulating cold pad with pump (E0218), provided on February 16, 2023, 
through March 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate. 
 
You asked the Plan to pre-approve transurethral waterjet ablation of prostate. You say that transurethral 
waterjet ablation of prostate is medically necessary. The Plan denied your request. The Plan says under 
Medicare guidelines, your request is not medically necessary because your records show that your peak flow is 
greater than 15, you have not had a transrectal ultrasound to evaluate the size of your prostate and you have not 
had an early detection evaluation for prostate cancer. 
 
The Plan follows Medicare rules. Medicare rules say that transurethral waterjet ablation of prostate is covered 
when the criteria listed in the Medicare rules section of this decision are met. 
 
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 transurethral waterjet ablation of 
prostate. Our reviewer says that transurethral waterjet ablation of prostate is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the records do not show that you have 
a prostate volume of 30-150 cc by transrectal ultrasound (TRUS). Also, you have a prostate nodule and 
elevated PSA and have not been evaluated for the presence of prostate cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation of prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate.