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

 
We decided that the Plan does not have to pay for the domiciliary visit provided on January 28, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on the hospital staff to 
verify eligibility and to obtain the proper authorization from the enrollee's insurance company. 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 
domiciliary visit. We found no exception that would require the Plan to pay for the domiciliary visit. The 
records provided for review do not show that the domiciliary visit was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on January 28, 2022, by an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for infusions provided on February 23, 2022, 
and February 28, 2022. 
 
You asked the Plan to waive the coinsurance for infusions. You say that you were told in the past these charges 
would be covered. The Plan denied your request. The Plan says the coinsurance applied 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 20% 
coinsurance for Medicare-covered Part B prescription drugs.  
 
You have been asked to pay $163.02 which is 20% of the allowed amount for the infusions. The allowed 
amount is $815.08 (20% x $815.08= $163.02).  Infusions fall within the Medicare Part B Prescription Drugs 
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 coinsurance for infusions provided on February 
23, 2022, and February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management service provided 
on April 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telephone evaluation and management service. You say that due to the 
ongoing crisis, you had less staff and unable to obtain authorization.  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 
telephone evaluation and management service. We found no exception that would require the Plan to pay for 
the telephone evaluation and management service. The records provided for review do not show that the 
service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the 
telephone evaluation and management service provided on April 11, 2022, by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the request for a home mechanical ventilator set in PS with Safety Tidal 
Volume mode that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. You have severe COPD with chronic CO2 
retention, and repeated hospitalizations for acute-on-chronic respiratory failure. You responded well to BiPAP 
as an inpatient and may benefit from ventilatory support during sleep as an outpatient. Average volume-assured 
pressure support (AVAPS) with a backup rate can be provided via BiPAP, and there is no evidence in the record that this has been tried at home. Medicare does not cover a home ventilator when used as BiPAP. Our 
physician reviewer found that your condition does not meet Medicare criteria for a portable ventilator. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on March 7, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this should be coded as 
surgery and not have a copayment. The Plan denied your request. The Plan says the copayment applied 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 $15 
copayment for services obtained from a specialist or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office (as 
permitted under Medicare rules).  
 
 You have been asked to pay $15 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors Office 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 copayment for specialist office visit provided on March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on November 11, 2021. 
 You asked the Plan to pay for the testing services. You say that the panel will guide appropriate medical 
management of the enrollee. The Plan denied your request. The Plan says the request does not meet Medicare 
rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The gene panel was billed with multiple codes. If a single procedure is 
performed, only one code with one unit of service may be reported for the procedure. Furthermore, the medical 
records do not show that the testing at issue was part of the physicians treatment plan. The records do not 
clearly document the physicians intent for the services to be provided. Based on this information, we decided 
that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the gene panel testing provided on November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that this was a follow up visit and the OON provider 
said there was an approved referral. The Plan denied your request. The Plan says the rendering provider is an 
OON provider and there was no referral from an in-network provider or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 
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 an office visit provided on February 15, 2022, 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 office visit provided on April 21, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that this was supposed to only be a routine 
eye exam and there would be no copayment. The Plan denied your request. The Plan says the copayment 
applied 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 $45 
copayment for each office visit to other providers. 
 
You have been asked to pay $45 copayment for office visit. Office visit falls within the Vision 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 office visit provided on April 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on March 30, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you thought there would be no charges. 
The Plan denied your request. The Plan says the copayment applied 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 $275 
copayment for advanced imaging services in an outpatient hospital.  
 
You have been asked to pay $275 copayment for CT scan. CT scans fall within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies 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 CT scan provided on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on February 1, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the vision services. You say that you would like to appeal these services. The 
Plan denied your request. The Plan says there was no referral from your primary care physician. 
 
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 
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 vision services provided on February 1, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on December 23, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing was reasonable for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says the testing is not a Medicare 
benefit. 
 
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 looked at the file and the rules. The gene panel at issue includes the FANCC gene. Panels of tests that 
include the FANCC gene are excluded. Based on this information, we decided that Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the gene panel provided on 
December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and wound debridement provided on January 
31, 2022, to February 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and wound debridement. You say that this provider is the only one 
in this area in the healing of ulcers, and he is not contracted. The Plan denied your request. The Plan says they 
have contracted providers in the same area of residence, the patient went to a non-contracted provider. 
 
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 an office visit and wound debridement provided 
on January 31, 2022, to February 10, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit, and the electrocardiogram 
(ECG) provided on February 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hospital outpatient clinic visit and the ECG. 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 
hospital outpatient clinic visit and the ECG. We found no exception that would require the Plan to pay for the 
hospital outpatient clinic visit and the ECG. The records provided for review do not show that the services at 
issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the hospital 
outpatient clinic visit, and the electrocardiogram (ECG) provided on February 11, 2022, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses provided on October 21, 2021. 
 
You asked the Plan to pay for the orthoses. The Plan denied your request. The Plan says the documentation did 
not sufficiently support the billed codes. 
 The Plan must follow Medicare rules. Medicare rules say that orthoses and orthopedic footwear are only 
covered under certain medical indications.  
 
The file shows that an ankle-foot orthosis (L1971) was provided. The records provided do not show that the 
enrollee has a weakness or deformity that requires stabilization. The file also shows that a heel stabilizer 
(L3170) was provided. The records do not show that the enrollee suffers from diabetic foot disease and does 
not wear a leg brace. Based on this information, we decided that the Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the orthoses provided on October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (LSO) provided on March 1, 2022. 
 
You asked the Plan to pay for LSO. You say that you are appealing with supporting documentation. The Plan 
denied your request. The Plan says the denial of payment for this item is correct, because the medical records 
do not state that this item was medically necessary for the enrollee.  
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. Medicare rules state that proof of delivery is required for durable medical 
equipment, prosthetics, orthotics, and supplies (DMEPOS) items. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a lumbar-sacral orthosis (LSO) 
provided on March 1, 2022. have been met. The documentation submitted does not include valid proof of 
delivery for the specific item billed on this claim. Therefore, we decided that the Plan does not have to pay for 
a lumbar-sacral orthosis (LSO) provided on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on October 28, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing was medically necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says the testing is not a 
Medicare benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We find that the gene panel at issue included the FANCC gene. Panels of tests that include the FANCC gene 
are statutorily excluded. Based on this information, we decided that Medicare rules for coverage of the testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the gene panel testing provided 
on October 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on February 10, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you feel this test was unnecessary so it 
should be covered. The Plan denied your request. The Plan says the copayment applied 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 $225 
copayment for advanced imaging service (not including x-rays).  
 
You have been asked to pay $225 copayment for CT scan. CT scan falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies 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 CT scan provided on February 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on February 5, 2022. 
 You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says the billed service exceeds the maximum number of 
units by this provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The file shows that CPT code 99285 was billed twice on the same day by the same provider. Instead of billing 
separately, the physicians should select a level of service representative of the combined visits and submit the 
appropriate code for that level. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for the emergency room services 
provided on February 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services (70450, 71045) provided on November 
20, 2021. 
 
You asked the Plan to pay for the imaging services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says coding guidelines have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The 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. In this case, the documentation supports that the services that were 
billed are exact duplicates of another claim. Payment for these services will not be made. Based on this 
information, we decided that Medicare rules for coverage of the imaging services have not been met. Therefore, we decided that the Plan does not have to pay for the imaging services (70450, 71045) provided on 
November 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was 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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on March 8, 2022, by an out-of-network (OON) provider.