Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81340, 81342) provided on February 
11, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 has network providers 
available who can provide 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 laboratory services (81340, 81342) provided 
on February 11, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 30, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the one way travel allowance and routine venipuncture 
provided by an OON provider. 
 
You asked the Plan to pay for the one way travel allowance and routine venipuncture. You say that the 
laboratory is connected with the skilled nursing facility where the enrollee resides, and you provide all of their 
laboratory services. You also say that the enrollee is home bound, and does not have an option to choose who 
performs their lab services. The Plan denied your request. The Plan says the services were rendered by a non-
contracted provider. The Plan also says that 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 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. 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 one way travel allowance and routine 
venipuncture provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hearing exam provided by a participating 
provider on June 5, 2020. 
 
You asked the Plan to waive the copayment for a hearing exam. You say that you do not think you should be 
charged for this. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 hearing services.  
 
You have been asked to pay a $40 copayment for a hearing exam. A hearing exam falls within the hearing 
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 a hearing exam provided 
by a participating provider on June 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services 
provided from April 22, 2020, to May 1, 2020. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you thought 
this would be treated like a skilled nursing facility, not an inpatient hospital. You also stated that you were just 
transferred from one unit of the hospital to another, so a new copayment should not apply. The Plan denied 
your request. The Plan says you were charged this copayment 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 $375 
copayment per day for days 1-4 for inpatient care.  
 
You have been asked to pay a $375 copayment per day for days 1-4 for the inpatient rehabilitation services. 
The EOC clearly states that inpatient rehabilitation is considered an inpatient stay for which this inpatient cost 
sharing applies.  In addition, your EOC also states that a transfer to a separate facility type (such as an Inpatient 
Rehabilitation Hospital or Long Term Care) is considered a new admission for which a new copayment would 
apply. 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 rehabilitation services provided 
from April 22, 2020, to May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for actinic keratosis removal you had at an 
outpatient hospital facility on January 8, 2020. 
 
You asked the Plan to waive the copayment for the actinic keratosis removal. You say that you should not be 
charged a copayment for this lab service. The Plan denied your request. The Plan says you were assessed this 
copayment correctly.  The Plan says that because the allowed amount for this service is less than your 
copayment responsibility, you are responsible for the full cost. 
 
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 $260 
copayment for surgery and other services provided at an outpatient hospital facility.  
 
You seem to indicate in your appeal letter that you believe you shouldn't have a copayment for lab services.  
Please note that the services in dispute are NOT lab services-- the services at issue here are surgical services for 
the removal of actinic keratosis lesions. You have been asked to pay the full amount of $178.87 because it is 
less than your copayment obligation of $260 for the actinic keratosis removal. The actinic keratosis removal 
falls within the surgery and other services provided at an outpatient hospital facility 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 actinic keratosis removal you had on January 8, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost sharing for allergy injections you received on February 20, 
2020. 
 
You asked the Plan to waive the cost sharing for the allergy injections. You say that there should be no 
copayment for this service. The Plan denied your request. The Plan did not provide an argument. 
 
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 case file that the Plan submitted to us was substantially 
deficient.  It is difficult to even discern what this case involved.  The Plan failed to provide any documentation 
supporting this case including Notices of Denial, Explanations of Benefits, or even any explanations of how 
cost sharing was applied.  The Plan has not explained which category of cost sharing from their Evidence of 
Coverage they applied to this claim.  Without that, we cannot determine if the Plan processed this claim 
appropriately. It is the Plan?s obligation to substantiate cost sharing charged and they have failed to do so in 
this case. Therefore, we decided that the Plan has to waive the cost sharing for allergy injections you received 
on February 20, 2020.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on 
November 12, 2019 by an OON provider. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that you would like this 
claim reconsidered for payment. The Plan denied your request. The Plan says these services were rendered by a 
non-contracted provider. The Plan also says that the services were 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 has network providers 
available who can provide 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 ambulance service and ground mileage 
provided on November 12, 2019 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for infliximab injections (J1745) provided 
from March 10, 2020, to May 6, 2020. 
 
You asked the Plan to waive the cost-sharing for infliximab injections. You say that you do not understand 
these charges. The Plan denied your request. The Plan says these claims processed 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 20% 
coinsurance for chemotherapy drugs and all other drugs covered under Medicare Part B.  
 
You have been asked to pay a 20% coinsurance for infliximab injections. 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 cost-sharing for infliximab injections (J1745) provided from March 10, 2020, to May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services provided on September 12, 2019. 
 
You asked the Plan to pay for the ophthalmology services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
ophthalmology services. We found no exception that would require the Plan to pay for these services. 
Therefore, we decided that the Plan does not have to pay for ophthalmology services provided on September 
12, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of a duplex scan provided on February 3, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that this was denied due to an invalid diagnosis code; 
however, the most recent rule lists the billed diagnosis as appropriate. The Plan denied your request. The Plan 
says it was found that this service was ordered by an OON provider and performed OON without authorization 
being provided. As such, no payment can be made. 
 
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 has network providers 
available who can provide 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 interpretation of a duplex scan provided on 
February 3, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 20, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 2, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 20, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit services provided to the enrollee on June 5, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not submit the correct rendering taxonomy on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program.  
 
You are not eligible to bill Medicare. The Plan did not pre-approve the services. 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 office visit services provided to the enrollee on June 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a behavioral health inpatient admission provided from 
February 11, 2020, through February 20, 2020. 
 
You asked the Plan to pay for the behavioral health inpatient admission. The Plan denied your request. The 
Plan says prior authorization was not obtained by the provider or the facility. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a behavioral health inpatient admission provided from February 
11, 2020, through February 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0425, A0429) provided on April 20, 
2020. 
 
You asked the Plan to pay for ambulance services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not billed correctly. Please note the Plan has indicated the enrollee is not 
responsible or these charges; however, the provider has advised this claim will not be corrected. 
 
The Plan must follow Medicare rules. Medicare rules say that for ambulance service claims, institutional-based 
providers and suppliers must report an origin and destination modifier for each ambulance trip provided in 
HCPCS/Rates. 
 
We looked at the file and Medicare rules. The services at issue were not billed with the required modifiers. 
Based on this information, we decided that Medicare rules for coverage of ambulance services have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0425, A0429) 
provided on April 20, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant360 testing provided on November 13, 2019. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request. 
The Plan says that the denial of payment for this testing is correct, because this testing was not medically 
necessary and is not approved for this indication. 
 
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. 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this 
testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for 
Guardant360 testing provided on November 13, 2019.   
  
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: Favorable

 
We decided that the Plan has to pay for the outpatient office visit provided on September 27, 2019. 
 
You asked the Plan to pay for the outpatient office visit. You say that you were told that you would not have to 
pay anything. The Plan denied your request. The Plan says that you received services out of the area that are 
not considered emergency services or urgent care services. The Plan also says that an authorization was not 
obtained for the services. 
 
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. The Plan did not provide any medical records or show efforts of requesting 
medical records. Without medical records, we cannot determine if the out-of-area services were urgent or not. 
Therefore, the Plan has not shown that its decision to deny payment for these services is correct or justified by 
the health plan contract. Therefore, we decided that the Plan has to pay for the outpatient office visit provided 
on September 27, 2019.  
 
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 pay for the home visit provided. 
 
You asked the Plan to pay for Home visit for the evaluation and management of an established patient (99348). 
You say that the Plan should pay this claim. The Plan denied your request. The Plan says the billed code does 
not appropriately reflect the services provided by the LVN. 
 
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, the CPT Code Manual definition of code 99348 is Home visit for the evaluation and management 
of an established patient. 
 
We find that CPT code 99348 is not supported in the medical record. Specifically, there is no documentation 
that a physician was present during the home visit. Based on this information, we decided that Medicare rules 
for coverage of Home visit for the evaluation and management of an established patient (99348) have not been 
met. Therefore, we decided that the Plan does not have to pay for the home visit provided.