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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 related to end-stage renal disease (ESRD) provided on 
February 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 13, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sent the specimen to 
your laboratory to process, and you would like the claim reprocessed for payment. The Plan denied your 
request. The Plan says the rendering and referring providers are both OON providers and there was no 
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 the laboratory services provided on April 13, 
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 deductible for a specialist office visit provided on April 1, 
2022. 
 
You asked the Plan to waive the deductible for the specialist visit. You say that you were advised there would 
be no charge. The Plan denied your request. The Plan says the correct amount was applied to your deductible. 
 
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 $750 deductible which applies to certain items and services.  
 
The specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the specialist visit was received on April 1, 2022. Therefore, we decided that the Plan does 
not have to waive the deductible for a specialist office visit provided on April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the routine dental services provided from October 
7, 2021, to November 15, 2021. 
 
You asked the Plan to reimburse you for the routine dental services. You say that you should be reimbursed for 
the services that were recommended to you. You say that you detailed documentation was submitted in January 
2022 as you had coverage. You also say that you should not have had to pay any out-of-pocket expenses. The 
Plan denied your request. The Plan says the claim processed correctly. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or 
replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not 
covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the 
routine dental services provided from October 7, 2021, to November 15, 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 March 5, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you do not understand why this service is 
not being covered. The Plan denied your request. The Plan says this service is not covered because there was 
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 March 5, 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 March 5, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a supply allowance for a therapeutic continuous glucose 
monitor (CGM) provided on January 20, 2022. 
 
You asked the Plan to pay for the supply allowance for a therapeutic CGM. 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 supply allowance for a therapeutic continuous glucose 
monitor (CGM) provided on January 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
brain stem provided on February 23, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that the cost should be waived since it was 
an emergency. 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 $250 
copayment per day for diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay a $250 copayment for the MRI. The MRI 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 a magnetic resonance imaging (MRI) of the brain stem provided on February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay from December 23, 2021, 
to January 9, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you should not have to pay this 
copayment. 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 $295 per 
day from days 1 to 6 for inpatient hospital care ($295 x 3 days = $885).  
 
You have been asked to pay $885 for a 3-day inpatient stay. An inpatient stay falls within the 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 copayment for an inpatient stay from 
December 23, 2021, to January 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vascular surgery provided to the enrollee on June 14, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this code is not supported in the records submitted. 
 
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 37242 is "Vascular embolization or occlusion, inclusive 
of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance 
necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired 
arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that this appears to be a simple coding 
error. The billed code - CPT 37242 - specifically codes for arterial embolization, not for hemorrhage. 
 
We looked at this coder's review, the file, and Medicare rules. 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 vascular surgery provided to the enrollee on June 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient procedure provided on 
January 12, 2022, and a specialist appointment provided on February 8, 2022. 
 
You asked the Plan to waive the copayment for an outpatient procedure and a specialist visit. You say that the 
cost is too high, and you should not need to pay. The Plan denied your request. The Plan says the copayments 
applied were 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $400 copayment for Outpatient Surgery and Other Medical Services and a $30 copayment for 
Physician/Practitioner Services.  
 
The enrollee has been asked to pay a $400 copayment for an outpatient procedure and a $30 copayment for a 
specialist visit ($400 + $30 = $430). An outpatient procedure and a specialist visit fall within the Outpatient 
Surgery and Other Medical Services and Physician/Practitioner Services benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan.  This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for an outpatient procedure provided on 
January 12, 2022, and a specialist appointment provided on February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 16, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says the lab testing is not separately 
reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 
 Laboratories should bill the facility directly for laboratory 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 related to end-stage renal disease (ESRD) provided on February 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for a cataract eye surgery performed 
on April 14, 2022. 
 
You asked the Plan to waive or reduce the copayment for the eye surgery. You say that you cannot afford the 
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 $275 
copayment for each visit for surgery or services at an ambulatory surgical center.  
 
You have been asked to pay a $275 copayment for the eye surgery. The eye surgery 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 waive or reduce the copayment for a cataract eye surgery performed on 
April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus immunization and administration provided on 
February 8, 2022. 
 
You asked the Plan to pay for the immunization. You say that the provider advised the immunization would 
probably not be covered. You say that you were not informed the additional fee for the administration. You say 
that you cannot received immunizations in your arm. You also say that you feel this fee should be removed 
from your bill. The Plan denied your request. The Plan says the Tetanus vaccine and its administration is a 
pharmacy (Medicare Part D) benefit and is not covered under your medical benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the immunization have not been met. Specifically, the Tetanus vaccine nor the administration are 
covered under Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Tetanus 
immunization and administration provided on February 8, 2022.  
 
Benefits for the immunization may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a UroVysion Bladder Cancer Kit (88120). 
 
You asked the Plan to pre-approve UroVysion testing. You say that this test kit is medically necessary. The 
Plan denied your request. The Plan says criteria for coverage of this test kit are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve UroVysion testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the UroVysion Bladder Cancer genetic testing is not indicated for those without 
hematuria. There was no documentation that the enrollee had hematuria; therefore, this request for UroVysion 
Bladder Cancer Kit testing is considered not 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 UroVysion testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a UroVysion Bladder Cancer Kit (88120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of IRF admission based 
on medically necessity. The Plan denied your request. The Plan says the enrollee does not require an intensive 
level of therapy requiring a physician oversight and it 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 for weakness and was treated non operatively for a 
subdural hematoma that occurred after a fall during the hospitalization. Medical problems are stable. There are 
no complex nursing or rehabilitation needs. While the enrollee has a need for physical or occupational therapy, 
there is no documentation of a need for an intensive rehabilitation program. Medically necessary care can be 
provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that the enrollee needs physical therapy until they 
can see the surgeon. The Plan denied your request. The Plan says that there are no significant changes in ankle 
movement or strength. 
 
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 therapy visits. Our reviewer says that 
the coverage criteria has been met. Our physician reviewer found that the enrollee still has functional deficits 
with mobility, in particular negotiating stairs and uneven terrain. Therefore, additional therapy and the skills of 
a physical therapist would be appropriate to continue to meet these goals and transition to a home exercise 
program to ensure independence and minimize fall risk. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have been met. Therefore, we decided that the Plan has to pre-
approve 10 physical therapy visits.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need wound care and you cannot stand up or 
walk on your own and you need oxygen and you cannot drive to dialysis. The Plan denied your request. The 
Plan says based on Medicare guidelines, the IRF services you and/or your provider are requesting do not meet 
the requirements for approval. 
 
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 that you are medically stable and do not need a physical medicine and rehabilitation physicians close supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions. There is no acute nursing needs identified or documented.  
At the current functional level, you do not need 3 hours a day x 5 days a week of therapies. The documentation 
does not support the medical necessity due to lack of medical complexity and nursing needs, and high 
functional level for admission to an IRF. While you would benefit from physical therapy and occupational 
therapy, your rehabilitation needs can be safely provided in an alternate and low intensity setting such as in a 
skilled nursing facility. 
 
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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammography provided on 
February 21, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that there should be a $0 
copay for a screening mammogram. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for diagnostic procedures and tests.  
 
The record shows this was a diagnostic procedure and not screening, so you have been asked to pay a $75 
copayment for the diagnostic mammogram. The diagnostic mammogram 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 the diagnostic mammography provided on February 21, 2022.