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

 
We decided that the Plan does not have to pay for the laboratory services coded 88341, 88342, 88360, and 
88381 provided on June 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 codes 88341, 88342, 88360, and 88381 are not supported in the medical record. Specifically, 
these codes have a professional component/technical component of 1. These services were billed with a place 
of service of 22 (outpatient hospital). This means that rules for payment of this claim has not been met as the 
professional interpretation of a diagnostic test must be separately billed with modifier -26 by the interpreting 
physician. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 
88341, 88342, 88360, and 88381 provided on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder detect test (0012M) provided December 16, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you believe the evidence supporting the use of 
CxBladder as a medically necessary diagnostic service is well established and affirmed by Medicare. The Plan 
denied your request. The Plan says the service does not meet Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. CxBladder Detect has not been evaluated for Medicare coverage by 
the MolDx Program administered by Palmetto GBA. Only CxBladder Monitor has been evaluated and it is 
noncovered. Based on this information, we decided that Medicare rules for coverage of the genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for CxBladder detect test (0012M) 
provided December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the $200 you claim that you paid above your 
annual out-of-pocket maximum for hearing aids you purchased on January 22, 2021. 
 
You asked the Plan to reimburse you for the $200 you claim that you paid above your annual out-of-pocket 
maximum. You say that you should never have been billed for this item because you had met your out-of-
pocket maximum for the year. The Plan denied your request. The Plan says the hearing aids you purchased do 
not count towards your annual out-of-pocket maximum, so not additional reimbursement is warranted. 
 
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 up to $3000 per year.  In addition, hearing aids do not count towards your annual out-of-
pocket maximum amount. 
 
Records show that you purchased hearing aids on January 22, 2021, and the total price was $3200.  Because 
you have a $3000 maximum benefit for hearing aids, you were charged the remaining $200. Although you 
claim that you should not have to pay this remaining balance because you had met your out-of-pocket 
maximum for the year, we do not agree.  Your contract explicitly says that hearing aids do not count towards your annual maximum out-of-pocket amount.  This means that you can be charged any balance over your 
$3000 annual hearing aid benefit for these items, even if you have met your out-of-pocket maximum.  Based on 
this information, we decided that the Plan's rules for coverage of the $200 you claim that you paid above your 
annual out-of-pocket maximum have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for the $200 you claim that you paid above your annual out-of-pocket maximum for hearing aids 
you purchased on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 27, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-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 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 October 27, 2021, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Simponi Aria for the enrollee. 
 
You asked the Plan to pre-approve Simponi Aria. You say that this is medically necessary. The Plan denied 
your request. The Plan says that that there is no documentation the enrollee's previous treatment with this drug 
was effective, and it's still needed to treat her condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Simponi Aria. Our reviewer says that 
Simponi Aria is medically reasonable and necessary. The enrollee has a diagnosis of seropositive rheumatoid 
arthritis. The record indicates that the enrollee is also being treated with methotrexate. The Food and Drug 
Administration has stated that the requested drug is indicated for the enrollee's condition. Our physician 
reviewer found that the enrollee's condition meets criteria for coverage of Simponi Aria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi Aria have been met. Therefore, we decided that the Plan has to pre-
approve Simponi Aria for the enrollee.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomographic (CT) colonography (74263) and 
final reports with documentation of one or more dose reduction techniques (G9637) provided on December 14, 
2021. 
 
You asked the Plan to pay for the CT colonography and final reports with documentation. You say that the 
hospital tried to obtain an authorization for this service, but were told one was not needed. The Plan denied 
your request. The Plan says this is not a covered benefit because the records show this testing is described and 
billed as a screening test. 
 
The Plan must follow Medicare rules. Medicare rules say that a computed tomography (CT) colonography is 
not covered when used for screening, or in the absence of signs or symptoms of disease, regardless of family 
history or other risk factors for the development of colonic disease.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CT colonography and final reports with documentation have not been met. Therefore, we 
decided that the Plan does not have to pay for the computed tomographic (CT) colonography (74263) and final 
reports with documentation of one or more dose reduction techniques (G9637) provided on December 14, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator and nebulizer 
provided on February 21, 2022. 
 
You asked the Plan to waive the coinsurance for oxygen concentrator and nebulizer. You say that you have 
always been charged $19.12, and do not know why this amount was withdrawn from your account. The Plan 
denied your request. The Plan says the coinsurance amount 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 50% 
coinsurance for out-of-network oxygen concentrator and nebulizer. The allowed amount of this equipment is 
$86.53, but you have only been asked to pay $25.96 which is less than the 50% coinsurance for out-of-network 
durable medical equipment. 
 
You have been asked to pay less than 50% coinsurance for oxygen concentrator and nebulizer. Oxygen 
concentrator and nebulizer fall within the Durable Medical Equipment (DME) and Related 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 coinsurance for an oxygen concentrator and nebulizer 
provided on February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on January 07, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that the visit was for a preventive eye 
exam and do not feel you should be responsible for a copay. 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 $40 
copayment for each physician specialist visit for Medicare-covered services. Covered services include: 
Consultation, diagnosis, and treatment by a specialist.  
 
 
 
 
 
 You have been asked to pay a $40 copayment for office visit. Office visits fall within the Physician/Practitioner 
Services, including doctor's 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 office visit on January 07, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent hospital visit provided on May 26, 2021. 
 
You asked the Plan to pay for the hospital visit. You say that you would like this service reconsidered for 
payment. The Plan denied your request. The Plan says original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a subsequent hospital visit provided on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
January 21, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the provision of F1CDx to the enrollee meets 
the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file, and Medicare rules. The next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been 
met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test 
(0037U) provided January 21, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on October 13, 
2021 to November 12, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health services. You say that you were not aware that prior 
authorization was needed for these services. The Plan denied your request. The Plan says unauthorized, non-
plan care is not covered. 
 
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 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 outpatient mental health services provided on 
October 13, 2021 to November 12, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services provided from September 21, 
2021, to September 30, 2021. 
 
You asked the Plan to pay for SNF care. You say that these services were billed with a valid PDPM code for 
the services provided. The Plan denied your request. The Plan says that the billed code does not match what 
was pre-approved by the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan did not submit a compelling denial rationale in this case. 
The Plan has attested that the SNF services were authorized with a PDPM code that was calculated at the time 
that the approval was requested. Based on how the PDPM code is calculated, however, it is not reasonable to 
expect or require that the code requested for authorization be the code that is billed. The PDPM code billed 
must correspond to the enrollees actual condition and the services actually rendered during the statement 
period of the claim. It would therefore be expected that the billed code would differ from a code that was 
estimated prior to the services being rendered. The Plan has not made any argument that any of the digits of the 
billed PDPM code are incorrect or not supported, only that the specific code billed does not match what was 
approved. We find that this denial of payment has not been substantiated. Therefore, we decided that the Plan 
has to pay for skilled nursing facility (SNF) services provided from September 21, 2021, to September 30, 
2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 74230, 72040, 70100, 70310, 74240 
provided on February 16, 2022. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 codes 74230, 72040, 70100, 70310, 74240 are not supported in the medical record. 
Specifically, these services were provided in a nursing home setting. In addition, the provider is billing the 
technical component modifier and the professional component modifier on the same claim. Both the modifier 
26 and modifier technical component cannot be paid when billed by the same provider with the same Tax ID 
number. This means the claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to 
pay for the x-ray services coded 74230, 72040, 70100, 70310, 74240 provided on February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) scan and x-ray (73564, 73700) 
provided on March 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the computed tomography (CT) scan and x-ray. You say that the services should 
be covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and prior authorization was not 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 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 computed tomography (CT) scan and x-ray 
(73564, 73700) provided on March 17, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 2, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that you disagree with this denial. The Plan denied your 
request. The Plan says unauthorized, non-plan care is not covered. 
 
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. 
 
Neither your lab nor the referring provider are network providers 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 lab services provided on February 2, 2022 by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the full criteria for an inpatient 
rehabilitation stay. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for admission to an IRF. 
 
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 complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient's medical status does not require intensive physician and nursing oversight 
in an IRF. 
 
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 pre-approve an office visit/consultation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that it is difficult to get an appointment with your 
provider and you would have to wait months to reschedule. Your pain and lack of medical attention/proper 
treatment have deteriorated your overall quality of life. You cannot walk, you have frequent urination, and you 
have depression. The Plan denied your request. The Plan says you must use network providers to get medical 
care and services when network providers are available. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit/consultation to be provided by an out-of-network (OON) provider.