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

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on June 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 6, 2021, to 
November 4, 2021. 
 
You asked the Plan to pay for the home health services. You say that you feel these charges should be allowed 
because the Plan did not issue guidance stating a No Pay RAP was required within 5 days as a condition of 
payment. You also say that other final claims have been paid without the submission of the No Pay RAP. The 
Plan denied your request. The Plan says the non-contracted provider did not submit the RAP claim for services 
for dates of service October 6, 2021, to November 4, 2021, until November 23, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the home health services provided from October 6, 2021, to November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on April 28, 2022, by an out-
of-network provider. 
 You asked the Plan to pay for chiropractic services. You say that the provider, as well as the referring provider, 
are participating providers with Medicare. The Plan denied your request. The Plan says there is no referring 
provider involved in these services nor did the plan authorize these services in advance. 
 
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 chiropractic services provided on April 28, 2022, 
by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 82310, 83970 and 84100 
provided September 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says does not meet coding 
standards. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services coded as 82310, 83970 and 84100 provided September 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for home health care and inpatient hospital 
admission on February 10, 2022, to February 24, 2022. 
 
You asked the Plan to waive the cost-sharing for home health care and inpatient hospital admission. You say 
that you thought home therapy was covered. 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 $0 for 
each Medicare-covered services for home health care. Deductible does apply. Covered services include, but are 
not limited to: Part-time or intermittent skilled nursing and home health aide services (To be covered under the 
home health care benefit, your skilled nursing and home health aide services combined must total fewer than 8 
hours per day and 35 hours per week). Your contract with the Plan clearly says that you must pay 10% per stay 
for each Medicare-covered hospital admission/stay. Deductible does apply. Includes inpatient acute, inpatient 
rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care 
starts the day you are formally admitted to the hospital with a doctors order. The day before you are 
discharged is your last inpatient day. The provider billed in the amount of $19,071.30 and the allowed amount 
is $17,576.30. $19,071.30 - $17,576.30 = $1,495. This is less than 10% per stay, due to the out-of-pocket 
maximum being met. Therefore, results in the total cost-sharing amount of $1,495. 
 
You have been asked to pay $1,495, which is less than 10% per stay for home health care and inpatient hospital 
admission. Home health care and inpatient hospital admission falls within the Home health agency care and 
Inpatient hospital 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 cost-sharing for home 
health care and inpatient hospital admission on February 10, 2022, to February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services (11720, G0127) billed for date of service 
November 29, 2021. 
 
You asked the Plan to pay for the podiatry services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 11720 is bundled into payment for code G0127.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 11720 
has a bundled relationship with code G0127. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for podiatry services (11720, G0127) billed for date of service 
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 January 12, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you needed emergency help when you 
called the ambulance. You also feel that you saved the Plan money by not going to the hospital. The Plan 
denied your request. The Plan says this service is not covered when there is no transport. 
 
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 January 12, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adding a tooth to an existing partial denture (D5650) 
provided on March 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service should be covered. The Plan denied 
your request. The Plan says adding a tooth to an existing partial denture (D5650) is not covered by your routine 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for adding a 
tooth to an existing partial denture (D5650) provided on March 16, 2022.
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 this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 the enrollee was admitted without complex rehabilitation needs to restore function 
following an intensive care unit (ICU) stay. The enrollee does not require frequent physiatry oversight. Her medical problems are chronic and stable. She requires routine post-acute rehabilitation services to recover from 
an acute illness. The diagnosis of dementia compromises the enrollee's ability to respond to intensive 
rehabilitation. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the enrollee was a new patient seeing the 
provider. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 10, 2020. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 26, 2022 billed with 
codes 81194, 81301, 81455, & 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 26, 2022 billed with codes 81194, 81301, 81455, & 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on February 28, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you fell unconscious. You say that your 
husband called 911. You say that paramedics administered drugs and you regained consciousness soon after. 
You also say that you were advised the claim coding would be changed so that it would not be denied. The 
Plan denied your request. The Plan says since there was no transported 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 February 28, 2022. 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 February 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optune device (E0766). 
 
You asked the Plan to pre-approve these services. You say that the device will help prevent growth on the 
glioblastoma. The Plan denied your request. The Plan says that your request is not medically necessary because 
records show you have recurrent glioblastoma. 
 
The Plan must follow Medicare rules. Medicare rules say that tumor treatment field therapy (E0766) will be 
denied as not reasonable and necessary for the treatment of recurrent Glioblastoma Multiforme (GBM). 
 
We looked at the file and Medicare rules. The file indicates you have recurrent GBM. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Optune device (E0766).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on April 1, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that the claim was processed under the group and 
not the rendering provider. The Plan denied your request. The Plan says these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 chiropractic services provided on April 1, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seventy (70) additional one-way routine transportation 
trips. 
 
You asked the Plan to pre-approve additional one-way routine transportation trips. You say that the trips are 
necessary. The Plan denied your request. The Plan says the request exceeds the enrollee's benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, the 101st trip 
and beyond is not a covered benefit. The Plan's denial letter from July 26, 2022, states the enrollee had one (1) 
trip remaining. The health plan contract says up to 100 one-way trips are covered each year (limited to ground 
transportation only). Therefore, the request for additional one-way routine transportation trips exceeds the 
enrollee's Plan benefits. Therefore, we decided that the Plan does not have to pre-approve seventy (70) 
additional one-way routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing in all four quadrants 
(D4341) provided on March 30, 2022. 
 
You asked the Plan to pay for periodontal scaling. You say that these services were medical necessary. The 
Plan denied your request. The Plan says periodontal scaling and root planing (D4341) is not covered by your 
routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal scaling and root planing in all four quadrants (D4341) provided on March 30, 2022.
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 February 26, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you were told you didn't need to go to the 
hospital. The Plan denied your request. The Plan says this service is not covered when there is no transport 
 
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 February 26, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided February 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) provided on December 10, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you would like to appeal the Plan's decision. The 
Plan denied your request. The Plan says you received these hearing aids from a provider that is not part of the 
Plan's vendor network. The Plan also says hearing aids are offered as an additional benefit; however, the 
hearing aids must be ordered through the Plan's approved hearing vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor to use your hearing aid benefits.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5298) provided on December 10, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 24, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on January 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient surgeries provided on October 
21, 2021, to October 25, 2021. 
 
You asked the Plan to waive the copayments for outpatient surgeries. You say that you have never had to pay 
this kind of copayment before. The Plan denied your request. The Plan says the copayment applied was 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 $150 
copayment for a surgery at an outpatient hospital facility (2 surgeries x $150 = $300 total).  
 
You have been asked to pay a $300 copayment for outpatient surgeries. Outpatient surgeries fall 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 waive the copayments for outpatient surgeries 
provided on October 21, 2021, to October 25, 2021.  
 Your complaint about not having to pay this type of copayment before, along with your plan premium 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.