Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 81178, 81179, 81180, 
81181, 81182, 81183, 81185, 81189, 81191, 81192, 81251, 81255, 81256, 81312, 81343, 81344, and 81479. 
We decided that the Plan does not have to pay for the services described by procedure code(s) 81171, 81175, 
81200, 81232, 81236, 81243, 81260, 81274, 81286, 81302, 81321, 81325, 81345, 81329, and 81309.  
 
You asked the Plan to pay for the lab testing billed for date of service May 31, 2023. The Plan says that an 
inappropriate place of service code was billed. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 81178, 81179, 81180, 
81181, 81182, 81183, 81185, 81189, 81191, 81192, 81251, 81255, 81256, 81312, 81343, 81344, and 81479.  
 
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 Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 81178, 81179, 81180, 81181, 
81182, 81183, 81185, 81189, 81191, 81192, 81251, 81255, 81256, 81312, 81343, 81344, and 81479.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
81171, 81175, 81200, 81232, 81236, 81243, 81260, 81274, 81286, 81302, 81321, 81325, 81345, 81329, and 
81309. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of have not been met. Therefore, we decided that the Plan does not have to pay for 
the services described by procedure code(s) 81171, 81175, 81200, 81232, 81236, 81243, 81260, 81274, 81286, 
81302, 81321, 81325, 81345, 81329, and 81309. 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1851) provided on September 7, 2023, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the orthosis. You say that kindly accept your request and reprocess your claim.  
The Plan denied your request. The Plan says the records so not show that the enrollee met the criteria for 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee presented on September 7, 2023, with right knee pain, left knee pain, and low back 
pain. A knee orthosis was requested by the durable medical equipment (DME) vendor. However, the provided 
documentation did not clearly show record of the enrollee's treating physician documenting the enrollee with 
objective knee instability on examination or having a recent injury or surgery or plans for such to justify this 
special knee orthosis with adjustable flexion and extension joint. Therefore, the documentation does not 
support the enrollee needs the knee brace at this time.  
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the knee orthosis (L1851) provided on September 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 a uvulectomy (42140 x2). 
 
You asked the Plan to pre-approve a uvulectomy. You say that this is medically necessary. The Plan denied 
your request. The Plan says the clinical value and effectiveness of uvulectomy in the setting of snoring of 
unknown etiology have not been demonstrated in the peer-reviewed literature. The record provided does not 
establish the medical necessity for a uvulectomy. 
 
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 uvulectomy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient literature to support the safety and efficacy, as defined by Medicare rules, 
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 uvulectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a uvulectomy (42140 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 22, 2023. 
 
You asked the Plan to pay for laboratory services. 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 laboratory services 
provided on June 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided on May 23, 
2023, to May 27, 2023. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that this copayment is too high and 
you cannot afford it on your fixed income. 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 $335 
copayment for inpatient hospital care.  
You have been asked to pay a $335 copayment for an inpatient 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 $1,340 for the inpatient hospital stay ($335 copayment x 4 days = 
$1,340). You have not been charged for the day you were discharged. Therefore, we decided that the Plan does 
not have to waive the copayment for an inpatient stay provided on May 23, 2023, to May 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive medicine reevaluation and the laboratory 
services provided on June 22, 2023. 
 
You asked the Plan to pay for the preventive medicine reevaluation and the laboratory services. 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 the preventive medicine 
reevaluation and the laboratory services provided on June 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan, 
thorax provided on February 24, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan, thorax. You say that you 
feel you should not have to pay the copayment for this test. 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 $150 
copayment for outpatient diagnostic tests and therapeutic servicesand supplies. 
 
You have been asked to pay a $150 copayment for the computed tomography (CT) scan, thorax. This 
item/service falls within the outpatient diagnostic tests and therapeutic servicesand 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. Therefore, we decided that 
the Plan does not have to waive the copayment for the computed tomography (CT) scan, thorax provided on 
February 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humira. 
 
You asked the Plan to pre-approve Humira. The Plan denied your request. The Plan says that self-administered 
drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Humira.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient admission from June 7, 2023, through June 9, 2023. 
 
You asked the Plan to pay for inpatient admission from June 7, 2023, through June 9, 2023. You say that the 
services were medically necessary. The Plan denied your request. The Plan says that the services were not 
authorized. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for inpatient admission from June 7, 2023, through June 9, 2023, by a contract 
provider. The file does not show that the plan provided notice that inpatient admission from June 7, 2023, 
through June 9, 2023, would not be covered. Under Medicare rules, this means inpatient admission from June 
7, 2023, through June 9, 2023, is considered approved by the plan. Therefore, we decided that the Plan has to 
pay for inpatient admission from June 7, 2023, through June 9, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telemedicine visit provided on July 17, 
2023, to August 10, 2023. 
 
You asked the Plan to waive the copayment for telemedicine visit. 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 $30 
copayment for physician/practitioner services/telemedicine visit. 
 
You have been asked to pay a $30 copayment for telemedicine visit. This item/service falls within the 
physician/practitioner services/telemedicine visit 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 $60 ($30 x 2 visits = $60). 
Therefore, we decided that the Plan does not have to waive the copayment for telemedicine visit provided on 
July 17, 2023, to August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve ablation. 
 
You asked the Plan to pre-approve the genicular nerve ablation. You say that after positive diagnostic nerve 
blocks you are requesting radiofrequency ablation (RFA). The Plan denied your request. The Plan says the 
request 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 genicular nerve ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that genicular nerve blocks and genicular nerve ablation are considered 
experimental/investigational and are not medically necessary for the treatment of chronic knee pain. 
 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 genicular nerve ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular nerve ablation.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31237 billed for date of service October 18, 
2023.  
 You asked the Plan to pay for procedure code 31237. You say that the physician performed debridement of 
bilateral nasal sinuses for post-op treatment. The Plan denied your request. The Plan says the number of units 
billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 31237 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 31237 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 31237 billed for date of service October 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010). 
 
You asked the Plan to pre-approve an endosteal implant. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not covered. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical placement of implant body: endosteal implant (D6010).
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 a hospital bed. You say that without an automatic bed the enrollee is at a 
higher risk of falling or experience pain to joints if not able to adjust bed position automatically. The Plan 
denied your request. The Plan says under Medicare guidelines, total electric hospital beds are not 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a folding walker with seat attachment. 
 
You asked the Plan to pre-approve a walker with seat attachment. You say that your current walker is 
insufficient for use outside of the home. The Plan denied your request. The Plan says this is a duplicate item. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you already have a folding walker. Therefore, we decided that the Plan does not have to 
pre-approve a folding walker with seat attachment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring treatment management 
services provided on August 31, 2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for remote physician services. You say that the enrollee was unable to select a 
network provider, given the location of the services. The Plan denied your request. The Plan says that their 
original decision to deny payment was correct. 
 
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 remote physiologic monitoring treatment 
management services provided on August 31, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the requested CGM would help monitor your blood 
sugar levels. The Plan denied your request. The Plan says that the Medicare criteria was not met. 
 
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. We find that specifically, the Plan did not collect medical records from their 
participating provider who ordered the requested CGM. Participating providers are considered agents of the 
Plan. Without this necessary documentation we are unable to make a determination as to whether the enrollee 
has met the criteria for coverage of a CGM. Confirmation of requests are not an acceptable substitution for 
medical records. Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor (CGM).  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
November 27, 2022. 
 You asked the Plan to pay for the ED services. You say that you have provided medical records so that the 
claim can be processed. The Plan denied your request. The Plan says Medicare payment cannot be made to this 
type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on November 
27, 2022.