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

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure coded 81479 
provided on August 26, 2020. 
 
You asked the Plan to pay for the unlisted molecular pathology procedure. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 81479 is the unlisted molecular pathology procedure. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the documentation does not 
support that the test was ordered by a physician who is treating the enrollee. Any tests not ordered by the 
physician who is treating the enrollee are not reasonable and necessary. Based on this information, we decided 
that Medicare rules for coverage of the unlisted molecular pathology procedure have not been met. Therefore, 
we decided that the Plan does not have to pay for the unlisted molecular pathology procedure coded 81479 
provided on August 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 10, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 10, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit provided on July 16, 
2020. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received a specialist visit on the date of service at issue in this appeal. The Plan 
says that the correct copayment has applied per your contract with the Plan. 
 
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 $45 
copayment for each specialist in-person office visit.  
 
We looked at the file, the Plan's contract and Medicare rules. You have been asked to pay a $45 copayment for 
the specialist visit. The specialist visit falls within the Physician/Practitioner 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 the specialist visit provided on July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on June 15, 2020. 
 
You asked the Plan to pay for the dental services. 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 when provided by 
a provider who has opted out of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental 
services provided on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac injection. 
 
You asked the Plan to pre-approve a sacroiliac injection. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are 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 a sacroiliac injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic low back pain, bilateral hip pain and tenderness over the 
sacroiliac joints. The enrollee is taking hydrocodone for pain. There is no documentation of other physical 
exam testing of the sacroiliac joint and no imaging of the sacroiliac joint (e.g. a CT scan). There is no 
documentation of a home exercise program or physical therapy. Therefore, the enrollee does not meet criteria 
for the requested services. 
 
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 sacroiliac injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac injection.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the mammogram provided on June 23, 
2020. 
 
You asked the Plan to waive the coinsurance for the mammogram. You say that you were told the facility was 
within your plan. You say you were only getting a routine mammogram. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
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 50% 
coinsurance for a breast cancer screening (mammograms) at an out-of-network freestanding radiological 
facility.  
 
You have been asked to pay $107.71 which is 50% of the allowed amount for the mammogram. The allowed 
amount is $107.71. ($215.42 x 50% = $107.71). The mammogram falls within the "Breast cancer screening 
(mammograms)" benefit category. The record shows the facility is out-of-network. 
 
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 coinsurance for the mammogram provided on June 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from April 21, 2020, to April 
22, 2020. 
 
You asked the Plan to pay for the medical services. You say that during this time, supportive care and 
conservative management were provided to the enrollee. The Plan denied your request. The Plan says the 
enrollee's emergency medical condition stabilized by 10:01 am on April 21, 2020. The Plan also says that 
subsequent care was post stabilization care, not approved in compliance with the Plan's authorization 
procedures. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 medical services. Our reviewer says that 
the services were not medically necessary. Our physician reviewer found the records did not show that the 
enrollee was not stable to transfer. Our reviewer also found that the enrollee appeared to be hemodynamically 
stable and with improvement in symptoms by 10:01 am on April 21, 2020. 
 
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 medical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services provided from April 21, 2020, to April 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71045) provided on August 15, 2019. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this service 
denied as a duplicate in error. The Plan denied your request. The Plan says this is a duplicate claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the chest x-ray have not been met. Specifically, the record indicates that a claim for this service 
rendered by the same provider was previously processed and paid by the claim. There is no indication in the 
record that this procedure was rendered more than once. Therefore, we decided that the Plan does not have to 
pay for the chest x-ray (71045) provided on August 15, 2019.
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 you would like reconsideration because you are not 
receiving the appropriate amount of rehabilitation in the hospital to be able to return home safely. The Plan 
denied your request. The Plan says your needs can be met in a lower 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 a lower 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on April 30, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with 
these services. 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 physician/practitioner services/specialist.  
 
You have been asked to pay a $40 copayment for a specialist office visit. The correct copayment has been 
applied to the services that were provided. A specialist office visit falls within the physician/practitioner 
services/specialist 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 specialist office 
visit provided by a participating provider on April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for refraction provided on July 8, 2020. 
 
You asked the Plan to pay for the refraction. You say that you cannot afford the refraction charge. The Plan 
denied your request. The Plan says the refraction was not provided by the preferred provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. The record shows this was a medical vision check and not covered in 
this setting. Based on this information, we decided that the Plan's rules for coverage of refraction have not been 
met. Therefore, we decided that the Plan does not have to pay for refraction provided on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan does not have to pre-approve an extraction (D7140) for tooth #19. 
 
You asked the Plan to pre-approve an extraction. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that this will not be covered due to the number of times this service has 
been reached. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers an extraction 
when the services are medically necessary and reasonable. 
 
We looked at the file and Medicare rules. The file indicates extractions are a covered benefit without a benefit 
limit. Based on this information, we decided that the Plan's rules for coverage of an extraction have been met. 
Therefore, we decided that the Plan does not have to pre-approve an extraction (D7140) for tooth #19.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
October 6, 2020. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received emergency care services on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $120 
copayment for Emergency care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room 
services on October 6, 2020. You have been asked to pay a $120 copayment for the emergency room services. 
The emergency room services fall within the Emergency 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. Therefore, we decided that the Plan does not have 
to waive the copayment for the emergency room services provided on October 6, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic medial branch blocks. 
 
You asked the Plan to pre-approve the medial branch blocks. You say that you would like reconsideration 
because this service is medically necessary. The Plan denied your request. The Plan says the injections is not 
supported because the member has a problem with their nerve, spinal cord or brain function that has caused 
numbness or tingling. 
 
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 medial branch blocks. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the request does not meet the criteria of the LCD as the member has cervical 
radiculopathy. 
 
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 medial branch blocks have not been met. Therefore, we decided that the 
Plan does not have to pre-approve diagnostic medial branch blocks.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from August 19, 2020, 
to September 4, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
required no nursing services which would be considered skilled services by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
 
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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from August 19, 2020, to September 4, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
October 22, 2020. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received laboratory services on the date of service at issue in this appeal. The 
Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $10 
copayment for Outpatient diagnostic tests.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received laboratory 
services on October 22, 2020. You have been asked to pay a $4.02 copayment for the laboratory services, 
which is less than the contracted $10 copayment amount. The laboratory 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 copayment for the laboratory services 
provided on October 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a laboratory test (82947) and an x-ray 
(72220) provided on October 21, 2020 and October 28, 2020. 
 
You asked the Plan to waive the copayments for the lab test and x-ray. You say that you should not have a 
copay for these services because they were provided as part of your standard wellness visit. The Plan denied 
your request. The Plan says lab tests and x-rays are separate billable services not covered by a wellness visit. 
Lab tests and x-rays are each subject to a $10 copayment. 
 
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 $10 
copayment for laboratory testing and a $10 copayment for x-ray exams.  
 
You have been asked to pay a $3.93 copayment for the lab test and a $10 copayment for the x-ray. Both 
services fall within outpatient diagnostic tests and therapeutic services and supplies benefit category. Neither is 
included in a standard wellness exam. The amount you paid for each service is equal to or less than the amount 
required by the Plan. 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 copayments for the laboratory test (82947) and 
x-ray (72220) provided on October 21, 2020 and October 28, 2020.