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

We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99213) 
provided on December 16, 2019, to December 30, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that the services 
provided were medically necessary. 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 established patient office or other outpatient 
visit (99213) provided on December 16, 2019, to December 30, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Capecitabine (J8521). 
 
You asked the Plan to pre-approve Capecitabine. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Capecitabine. Our reviewer says that 
the medication is not medically necessary. Our physician reviewer found the documentation does not support 
that Capecitabine is medically reasonable and necessary for this enrollee with metastatic squamous cell skin 
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 Capecitabine have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Capecitabine (J8521).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided 
on June 18, 2020. 
 
You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Comprehensive Genomic Profile (CGP) testing provided on June 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the colonoscopy services provided on June 11, 
2020. 
 
You asked the Plan to waive the copay for the services provided. You say that the charge is rightfully the plan's 
responsibility. The Plan denied your request. The Plan says when polyps are removed, the procedure is no 
longer a preventive screening test. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copay for each visit to an outpatient hospital facility for outpatient surgery.  
 
The documentation shows that you received a diagnostic colonoscopy, which included the removal of polyps. 
You have been asked to pay a $350 copay for the services provided. The services fall within the outpatient 
surgery 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 copay for the colonoscopy services 
provided on June 11, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care provided on December 2, 2019. 
 
You asked the Plan to pay for the wound care. You say that there is no indication that the enrollee was enrolled 
in hospice. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the 
member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the wound care provided on December 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the genetic testing provided on August 19, 
2020. 
 
You asked the Plan to waive the cost share for the services provided. You say that you should not have to pay 
for something you did not request. The Plan denied your request. The Plan says the coinsurance is a contractual 
obligation. 
 
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 molecular or predisposition genetic testing.  
 
You have been asked to pay a 20% coinsurance for genetic testing. The services fall within the outpatient 
diagnostic tests 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 cost share for the genetic testing provided 
on August 19, 2020.  
 
Your complaint about not requesting the testing services is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient services provided from March 
18, 2020, to March 23, 2020. 
 
You asked the Plan to waive the copayment for the inpatient services. You say that there should be no 
copayment for the Covid-19 related services. The Plan denied your request. The Plan says the you were not 
charged for Covid-19 screening/testing and the inpatient services were for COPD complications. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $325 copayment per day for days 1-5 for Inpatient Hospital Care.  
 
The enrollee has been asked to pay a $325 copayment per day for days 1-5 for the inpatient services. the 
inpatient services fall within the Inpatient Hospital Care benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for the inpatient services provided from March 18, 2020, to March 23, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the DNA gene analysis of 324 genes in solid organ tumor tissue 
(0037U) provided on June 11, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the DNA gene analysis of 324 genes in solid organ tumor tissue. You say that the 
Foundation One test is not available through any other lab. The Plan denied your request. The Plan says that the 
provider is a non-par Medicare provider and cannot be identified as being a certified/par-Medicare provider. 
 
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 the DNA gene analysis of 324 genes in solid organ tumor tissue by the provider. 
The provider is a contract provider. The file does not show that the plan provided notice that the DNA gene 
analysis of 324 genes in solid organ tumor tissue would not be covered. Under Medicare rules, this means the 
DNA gene analysis of 324 genes in solid organ tumor tissue is considered approved by the plan. The Plan has 
not provided any information to show that the provider in this case does not participate with Medicare. The 
record contains a letter from the Centers for Medicare and Medicaid Services (CMS) showing that the 
Foundation One test was approved by CMS for a new Advanced Diagnostic Laboratory Test (ADLT) status 
with the provider at issue. Therefore, we decided that the Plan has to pay for the DNA gene analysis of 324 
genes in solid organ tumor tissue (0037U) provided on June 11, 2020, by an out of network (OON) provider.  
 
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 services provided on June 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says it cannot be 
determined if the services were necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. The documentation submitted by the non-contract provider does not 
contain medical records for the date of service in question. Without records, it cannot be determined that 
Medicare coverage criteria have been met. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
services provided on June 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on February 20, 
2020. 
 
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 denied codes remain not supported. 
 
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 the denied codes is: 
 
CPT 80157: 
 
Carbamazepine; free testing 
 
CPT 80159: 
 
Clozapine testing 
 
CPT 80162: 
 
Digoxin; total testing 
 
CPT 80173: 
 
Haloperidol testing 
 
CPT 80177: 
 
Levetiracetam testing 
 
CPT 80201: 
 
Topiramate testing  
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
documentation submitted was reviewed and does not meet criteria. Per AMA CPT guidelines "Material for 
examination is whole blood, serum, plasma, or cerebrospinal fluid.  Laboratory report submitted documents 
urine collected.  Therefore, these codes cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee on February 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
needs can be met at an alternate level of care. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says screening tests are not 
covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on April 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 7, 2020. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed 
services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
services provided on February 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3 prosthesis and components (L5321, L5650, L5631, 
L5651, L5652, L5624, L5679, L5828, L5845, L5920, L5925, L5950, L5981, L5984, L5988, L7700, L8430, 
L8480) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request exceeds the enrollee's need. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not reveal objective recent physician progress notes that indicate that the 
enrollee is currently a K3 ambulator. The prior review indicates that the enrollee had left leg ischemia issues in 
August 2020 and there are no recent objective physician medical progress notes indicating the enrollee's current 
functional level and medical status therefore this request for a K3 prosthesis and components 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a K3 prosthesis and components (L5321, L5650, L5631, L5651, L5652, L5624, L5679, 
L5828, L5845, L5920, L5925, L5950, L5981, L5984, L5988, L7700, L8430, L8480) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on September 12, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the primary insurer 
must be billed first. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the 
primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary 
insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the 
services provided on September 12, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the primary care new patient visit provided on March 31, 
2020. 
 
You asked the Plan to hold you harmless for the new patient visit. You say that you were told you needed to 
find a new primary physician (PCP) since your former PCP was retiring. You state that you were referred to 
this provider and had no idea that this would be denied. The Plan denied your request. The Plan says that it was 
confirmed that you were not referred to this provider by your prior PCP's office. You went to a provider who 
was not your assigned PCP without referral or authorization which is required by your Plan. It is noted that you 
did switch to this new provider but that the effective date was not until April 1, 2020, the day after this visit. 
 
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. 
 
You were seen by a network provider to establish PCP care due to your prior PCP retiring. Although you may 
not have been referred to this new PCP directly by your former provider, the Plan notes that your account was 
updated to reflect the new PCP you saw, effective on April 1, 2020. Since the plan was aware of the intention 
to switch PCPs, this new provider is expected to have access to that information, including the effective date. 
Because this provider saw you a day before the new PCP assignment went into effect without informing you 
that you would be responsible for the charges, this visit is considered approved by the Plan. Therefore, we 
decided that the Plan has to hold you harmless for the primary care new patient visit provided on March 31, 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 20, 2020. 
 
You asked the Plan to pay for the lab services. You say that the ordering provider determined that the test is 
medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare pays for a limited 
number of telehealth services. 
 
The Plan must follow Medicare rules. Medicare enrollees are eligible for telehealth services only if they are 
presented from an authorized originating site located in either a county outside of a MSA or HPSA located in a 
rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are 
likewise non-covered. Therefore, we decided that the Plan does not have to pay for the lab services provided on 
April 20, 2020.