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

 
We decided that the Plan does not have to pay for the hospital services rendered August 24, 2023, to August 
25, 2023.  
You asked the Plan to pay for the hospital services. You say that the services rendered were for an emergency 
condition. The Plan denied your request. The Plan says The Plan does not pay providers outside the United 
States directly. The enrollee is responsible for paying for emergency services received outside of the United 
States at the time they receive services and submit receipts to the Plan for reimbursement for the difference 
between the amount of the bill and their cost share for the services as outlined in the EOC. 
 
The Plan must follow Medicare rules. Medicare rules say that certain services provided outside of the United 
States are covered under certain conditions.  
 
We looked at the file and Medicare rules. The Plan does not pay providers outside the United States directly for 
emergency services. The enrollee is responsible for paying for emergency services received outside of the 
United States at the time they receive services and submit receipts to the Plan for reimbursement for the 
difference between the amount of the bill and their cost share for the services as outlined in the Plan Evidence 
of Coverage. The Plan is unable to pay this claim as billed. Based on this information, we decided that 
Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that the Plan 
does not have to pay for the hospital services rendered August 24, 2023, to August 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 You asked the Plan to pre-approve the home ventilator. You say that the equipment will assist with preventing 
exacerbations. You also say that the enrollee has been hospitalized with respiratory failure 5 times in the last 6 
months. The Plan denied your request. The Plan says the request for the home ventilator does not meet 
guideline requirements. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home ventilator. Our reviewer says 
that the home ventilator is not medically necessary. Our physician reviewer found the enrollee was treated 
appropriately and tolerated with improvement on BiPAP therapy. The enrollee had no failure or escalation of 
therapy required. Hence, per documentation, no indication for home ventilator at this jurisdiction. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the manual wheelchair provided on 
October 19, 2023. 
 
You asked the Plan to waive the coinsurance for the manual wheelchair. You say that you refused the 
wheelchair and you think it should not be on your explanation of benefits. 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 durable medical equipment. 
 
You have been asked to pay 20% coinsurance for the manual wheelchair. This item/service falls within the 
durable medical equipment 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 $11.93, which is 20% coinsurance of the allowed amount ($59.67 
allowed amount x 20% = $11.93) Therefore, we decided that the Plan does not have to waive the coinsurance 
for the manual wheelchair provided on October 19, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan does have to pay for a diagnostic consultation (D9310) and pulp vitality tests (D0460) 
provided on September 11, 2023. 
 
You asked the Plan to pay for a diagnostic consultation. You say that your primary dentist referred you to see 
an endodontic dentist to have your gum area cleaned. You also say that at the endodontic dentist, it was 
confirmed that your tooth could not be saved and needed to be pulled. The Plan denied your request. The Plan 
says this is not a covered service under your Plan. 
 
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 the Plan failed to submit the correct EOC. The Plan sent the 2022 
EOC, yet the date of services is September 11, 2023. Without the correct EOC, we are unable to verify if there 
is coverage, or to be able to determine what type of coverage the enrollee has regarding the requested service 
coverage. We requested the 2023 EOC, but the Plan failed to respond to that request. Therefore, we decided 
that the Plan does have to pay for a diagnostic consultation (D9310) and pulp vitality tests (D0460) provided on 
September 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBO). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is only covered for certain 
indications. 
 
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 hyperbaric oxygen therapy. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has a diagnosis of Hidradenitis suppurativa and diabetes 
mellitus. The documentation indicates the enrollee has a chronic wound to the lower abdomen/periumbilical 
region. The documentation does not support that the wound is due to the diagnosis of diabetes mellitus. In this 
case, the documentation available for review does not support that the wound intended for treatment by HBO is 
a diabetic wound involving the lower extremity. The enrollee does not have an appropriate wound for the 
administration of HBO. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy (HBO).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Ossur Proflex ST foot (L5968 + L5981). 
 
You asked the Plan to pre-approve the Ossur Proflex ST foot. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item is not medically necessary. 
 
=The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 Ossur Proflex ST foot. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found there is no treating physician 
documentation indicating functional level or corroborating prosthetist notes. 
 
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 Ossur Proflex ST foot have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Ossur Proflex ST foot (L5968 + L5981).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on April 13, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you should not have 
copayments this high. 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 $225 
copayment for each Medicare-covered service or one-way trip by ground transportation. 
 
You have been asked to pay a $225 copayment for ambulance services. This item/service falls within the each 
Medicare-covered service or one-way trip by ground transportation 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 ambulance services provided on April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
August 23, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be 
responsible for the copayment since a nurse practitioner does not have the same education as a physician. 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 $40 
copayment for physician/practitioner services, including a specialist office visit.  
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including a specialist office 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. Therefore, we decided that the Plan does not have 
to waive the copayment for the specialist office visit provided on August 23, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Peripheral Nerve Stimulation (PNS). 
 
You asked the Plan to pre-approve PNS. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PNS. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic right shoulder pain. The enrollee has had physical therapy and 
diagnostic right suprascapular nerve block with good relief. The enrollee's medication trials have included 
Tylenol, Voltaren gel, Compounded analgesic cream, Indomethacin, and Oxycodone/Acetaminophen. The 
enrollee had a psychological evaluation and was cleared for a trial of Peripheral nerve stimulation. The pain 
appears to be mediated by right suprascapular nerve and is chronic unremitting not responsive to conservative 
therapy. Therefore, the request is deemed 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 PNS have been met. Therefore, we decided that the Plan has to pre-approve 
Peripheral Nerve Stimulation (PNS).  
 
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 pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that the follow up services are medically necessary. 
The Plan denied your request. The Plan says the enrollee must receive their care from a network provider. 
 
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 Plan has network providers available who are capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 an office visit to be provided by an out-of-
network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service May 8, 2023, 
to June 8, 2023. You asked the Plan to pay for the billed services. You say that an NOA is not required. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 11, 2023. The NOA was not received by the Plan until September 7, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care billed for 
dates of service May 8, 2023, to June 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 21, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not urgent or emergent. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 provided on September 21, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88333 billed for date of service August 9, 
2023. 
 You asked the Plan to pay for procedure code 88333. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 88333 is bundled into payment for code 88173. 
 
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 code 88333 
is a column II code to column I code 88173. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 88333 billed for date of service August 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) 
provided on August 17, 2023. 
 
You asked the Plan to waive the copayment for the magnetic resonance imaging (MRI). You say that you see 
no reason why the Plan paid zero for the 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 $300 
copayment for in-network outpatient diagnostic tests, including an MRI. 
 
You have been asked to pay a $300 copayment for the magnetic resonance imaging (MRI). This item/service 
falls within the in-network outpatient diagnostic tests, including an MRI 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. However, since the allowed amount is 
less than the standard copayment, you only owe $255.34. Therefore, we decided that the Plan does not have to 
waive the copayment for the magnetic resonance imaging (MRI) provided on August 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service September 6, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the test creates an informed treatment protocol. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
 The panel testing was billed using codes 87481, 87500, 87640, 87652, 87798, 87799, and 87900. We looked at 
the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. 
There is no evidence that multiple procedures, multiple methodologies, or multiple kits were used in this case. 
As such, a single code with one unit of service should be used. Based on this information, we decided that 
Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the panel testing billed for date of service September 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 11, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the claim submitted for RNA testing via 
CPT code 81456 should be covered. The Plan denied your request. The Plan says payment for code 81456 is 
bundled into payment for code 81455. 
 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 code 81456 
is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 code 81456 billed for date of service January 11, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services described by code 01937 billed for 
date of service May 3, 2023. 
 
You asked the Plan to pay for 01937. You say that 01937 should be paid as billed because it was coded 
accurately and other claims with the same diagnosis and procedure codes have paid previously. The Plan 
denied your request. The Plan says 01937 is denied because the diagnosis code assigned does not support 
medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis code M79.2 is not listed as a diagnosis 
code that supports medical necessity when billing procedure code 01937. 
 
We looked at the file and Medicare rules. In this case we have confirmed that procedure code 01937 was billed 
with a diagnosis of only M79.2, defined as neuralgia and neuritis, unspecified. No additional diagnoses were 
listed on the claim. We confirmed that per LCA A57361, M79.2 does not support medical necessity when billing 01937. As such, the denial of 01937 is appropriate. Based on this information, we decided that Medicare 
rules for coverage of 01937 have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services described by code 01937 billed for date of service May 3, 2023.