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

 
We decided that the Plan does not have to pay for the next generation sequence (NGS) testing panel provided 
on December 17, 2021. 
 
You asked the Plan to pay for the NGS testing panel. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels that include testing for the FANCC gene 
are non-covered.  
 
We looked at the file and Medicare rules. Review of the file shows that the NGS testing panel provided 
included testing for the FANCC gene. This means the entire panel is not covered. Based on this information, 
we decided that Medicare rules for coverage of the NGS testing panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the next generation sequence (NGS) testing panel provided on 
December 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an endoscopy performed on January 20, 
2022. 
 
You asked the Plan to reduce the copayment for the endoscopy. You say that your copayment should only be 
$295 for an ambulatory surgical center. 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 a $340 
copayment for surgery or other services provided at an outpatient hospital.  
 
The file shows that the procedure was performed at an outpatient hospital. Therefore, you have been asked to 
pay a $340 copayment for the endoscopy. The endoscopy falls within the Outpatient Surgery and Other 
Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 reduce the copayment for an endoscopy performed on January 20, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for behavioral health services provided on March 7, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the behavioral health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
behavioral health services. We found no exception that would require the Plan to pay for the behavioral health 
services. The records provided for review do not show that the behavioral health services were urgent or 
emergent. Therefore, we decided that the Plan does not have to pay for behavioral health services provided on 
March 7, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames (V2025) provided March 15, 2022. 
 
You asked the Plan to pay for the deluxe frames. You say that your glasses should be covered because they 
were ordered after cataract surgery. The Plan denied your request. The Plan says this lens upgrade is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that covered eyeglasses after cataract surgery include 
standard frames and lenses as defined by Medicare; any upgrades are not covered. 
 
Though Medicare covers standard frames and lenses after cataract surgery, the deluxe frame upgrade is not a 
covered service.  Therefore, we decided that the Plan does not have to pay for the deluxe frames (V2025) 
provided March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for the home ventilator provided on January 27, 2022, 
and February 27, 2022. 
 
You asked the Plan to waive the cost for the home ventilator. You say that you did not sign up for the new plan 
and should not have to pay the deductible for it. The Plan denied your request. The Plan says the claims 
processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1000 deductible per plan which applies to out-of-network services. 
Your contracts with the Plan also say that coinsurance also applies once your $1,000 deductible has been met. 
 
 
  The item or service you asked the Plan to waive the deductible for falls within the Durable Medical Equipment 
(DME) and Related Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in 
the contract that your $1000 deductible applies to out-of-network services. This cost sharing is a contractual 
obligation that had not been met at the home ventilator was provided on January 27, 2022, and February 27, 
2022. Therefore, $939.23 has been applied to meet the deductible for your January Plan and $855.38 has been 
applied to meet the deductible for your February Plan. 
 
Since the $1000 deductible was met, you have been asked to pay $16.98, which is 20% of the allowed amount 
for the home ventilator billed on January 27, 2022. You have also been asked to pay $28.69, which is 17% of 
the allowed amount for the home ventilator billed on February 27, 2022. 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 the Plan does not have to waive the 
cost for the home ventilator provided on January 27, 2022, and February 27, 2022. 
 
Your complaint about being enrolled in a plan without your consent 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an endoscopy performed on November 29, 
2021. 
 
You asked the Plan to reduce the copayment for the endoscopy. You say that this should be considered a 
diagnostic procedure with a $75 copayment. 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 a $150 
copayment for services provided at an outpatient hospital.  
 
You have been asked to pay a $150 copayment for the endoscopy. The endoscopy is considered a surgical 
procedure and falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities 
and Ambulatory Surgical Centers 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 reduce the copayment for 
an endoscopy performed on November 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on December 4, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you were experiencing arm tingling. You 
say that you called 911. You say that you feel you should not have to pay the ambulance charge. You also say 
that you cannot easily get to the hospital on your own and had medical issues. The Plan denied your request. 
The Plan says since there was no transport provided, there is no payable service. 
 
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 December 4, 2021. 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 response and treatment, no 
transport, (A0998) provided on December 4, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 12 additional outpatient physical therapy (PT) sessions. 
 
You asked the Plan to pre-approve additional PT sessions. You say that the enrollee has benefited from the 
skilled outpatient therapy services. You also say that the signed documentation from the referring physician 
justifies the appropriateness to continue with the established plan of care. The Plan denied your request. The 
Plan says that the enrollee does not meet the medical necessity guidelines for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT sessions. Our reviewer 
says that additional PT sessions are reasonable and necessary. Our physician reviewer found the clinical 
documentation shows that the enrollee has a neurodegenerative disease with functional impairments. The 
recommendation from the provider along with clinical goals were evaluated by a physical therapist. 
Assessment and treatment would require the skill of a professional therapist based on clinical documentation. 
Therefore, 12 additional physical therapy sessions are 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 additional PT sessions have been met. Therefore, we decided that the Plan has 
to pre-approve 12 additional outpatient physical therapy (PT) sessions.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. 
 
 
 
 
 
  
 This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for ultrasound and office visit on January 06, 
2022. 
 
You asked the Plan to waive the cost-sharing for ultrasound and office visit. You say that you want to appeal 
the amount being charged. The Plan denied your request. The Plan says the cost-sharing you are being charged 
is correct. 
 
 
 
 
 
 
 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 15% of 
the cost of diagnostic ultrasounds. Covered services include but are not limited to other outpatient diagnostic 
tests. You must pay a $40 copayment for each specialist office visit for Medicare-covered services. Covered 
services include consultation, diagnosis, and treatment by a specialist. The provider billed in the amount of 
$193 and the allowed amount is $53.63. $53.63 x 15% = $8.04. $40 + $8.04 = $48.04. Therefore, results in the 
total cost-sharing amount of $48.04.  
 
You have been asked to pay a 15% coinsurance for ultrasound and a $40 copayment for office visit. Ultrasound 
and office visits fall within the Outpatient diagnostic tests and therapeutic services and supplies and 
Physician/Practitioner services, including doctors visits 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-sharing for ultrasound and office visit on January 06, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the breast 
(77049). 
 
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says given the recent 
negative breast MRI, the medical necessity for repeat MRI at 6 months is not established. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI. Our reviewer says that an MRI 
is not reasonable and necessary. Our physician reviewer found the enrollee had a mammogram which was 
normal in 2021, and an MRI was normal less than 6 months ago. Our reviewer found that there was no recent 
evidence of a suspicious lesion or other signs of symptoms of the breast to warrant a repeat MRI at this time. 
Our physician reviewer also found that an MRI will be considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a magnetic resonance imaging (MRI) of the breast (77049).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this is necessary for your condition. The Plan 
denied your request. The Plan says this device is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records provided support the 
need for LTACH care. You say that an LTACH is the medically appropriate level of care and the most optimal 
opportunity for a successful outcome for the enrollee. The Plan denied your request. The Plan says a continued 
stay at the acute hospital is appropriate until the enrollee is table enough for discharge to a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with abdominal pain, weight loss, 
and failure to thrive. She was treated with antrectomy and vagotomy complicated by gastrointestinal bleed, 
acute respiratory failure, aspiration pneumonia, and ileus, requiring antibiotics, PPI and blood transfusions as 
well as OJ tube placement. Recent notes describe the enrollee as being NPO due to persistent nausea but is 
tolerating tube feeds and low dose oxygen support. The enrollee appears to be more stable and gradually 
improving and should only require short-term additional acute care services that can safely be completed at the current facility until more appropriate for a lower level of care. The enrollee does not require services at the 
LTACH that are not already available at the current facility. Transfer to LTACH is not medically necessary at 
this time as it would not be clinically advantageous. Completion of treatment at the current facility is 
recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on February 22, 2022. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records to validate 
the billed service. The Plan denied your request. The Plan says that the denial of payment for this test is correct, 
because the documentation submitted does not support that 22 or more drug classes were included in this 
testing. 
 
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 G0483 is drug test(s), definitive, qualitative or quantitative, all sources, includes specimen validity testing, 
per day; 22 or more drug classes, including metabolites if performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the test report submitted 
includes more than 22 drug classes. Based on this information, we decided that Medicare rules for coverage of 
drug testing have been met. Therefore, we decided that the Plan has to pay for drug testing provided on 
February 22, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Retacrit or Procrit. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Aranesp. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the required drugs. The reviewer found that there is no indication 
that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable x-ray services provided to the enrollee on February 
3, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says a nursing home is denied as an excluded place of service. 
 
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 CPT code 74230 and 74240 is not supported in the medical record. Specifically, these services are 
not valid for a nursing home. 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 portable x-ray services 
provided to the enrollee on February 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve office visit. You say that you have been seeing this physician for years and 
you want to continue care. The Plan denied your request. The Plan says this is denied due to the physician is 
out-of-network 
 
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 provider at issue in this case is not a network provider with the Plan. 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 office visit. Our reviewer says that this enrollee is not currently receiving 
any active treatment and/or medical management of enrollees condition that makes it medically necessary for 
this enrollee to continue care with the out-of-network Pain management provider as requested. There is not 
anything unique about this enrollees condition that would make it medically necessary for the enrollee to 
continue care with this provider. The plan has shown that they have in-network Pain Management specialists 
who have the qualifications and expertise necessary to meet the current medical Standards of Care required for 
treatment of the enrollees condition. This enrollees medical management and/or follow-up care be safely 
transitioned to an in-network Pain Management specialist at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of office visit have not been met.  
 
The Plan has network providers available who can provide the office visit at issue in this appeal. We found no 
exception that would require the Plan to pre-approve office visit. Therefore, we decided that the Plan does not 
have to pre-approve the office visit to be provided by an out-of-network (OON) provider.