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

 
We decided that the Plan does not have to pay for the laboratory services provided on November 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 provided on November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 2, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules 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 provided on February 2, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the cataract surgery services (66982, J0171, J0360, and J2250) 
provided on November 17, 2021. 
 
You asked the Plan to pay for the cataract surgery services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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. The Plan has provided no information as to the reasoning for the denial of 
payment for these services. The Plan has provided no supporting evidence based on Medicare criteria for why 
these services are not payable. It is the Plan's responsibility to provide a complete case file with supporting 
evidence showing how Medicare criteria was not met for payment to be made. Therefore, we decided that the 
Plan has to pay for the cataract surgery services (66982, J0171, J0360, and J2250) provided on November 17, 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on December 1, 
2021. 
 
You asked the Plan to waive the copayment for an ultrasound. 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 a $130 
copayment for Medicare-covered radiological diagnostic services.  
 
You have been asked to pay a $130 copayment for an ultrasound. An ultrasound falls within the Medicare-
Covered Radiological Diagnostic Services 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 ultrasound provided on December 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve radiofrequency ablation to the SI joint. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been 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 radiofrequency ablation to the SI joint. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this is considered an experimental/investigational procedure because of 
the wide variation in efficacy reported in the literature. Therefore, the request is deemed not medically 
reasonable or 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 radiofrequency ablation to the SI joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 2, 
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 the denied codes remain not supported. 
 
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. 
 
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 laboratory services provided to the 
enrollee on November 2, 2021 have been met. The provider has sent in any laboratory report or results from the testing at issue in this case. Therefore, we decided that the Plan does not have to pay for laboratory services 
provided to the enrollee on November 2, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to reimburse you for the durable medical equipment provided on December 12, 
2021. 
 
You asked the Plan to reimburse you for the durable medical equipment. You say that the item is medically 
necessary. The Plan denied your request. The Plan says that you do not meet Medicare criteria. 
 
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. The Plan says based on review of the additional clinical information received, 
you do not meet Medicare criteria for the item purchased. However, the Plan has not provided any of these 
medical records for review to confirm that you do not meet Medicare criteria. We find that the Plan has 
provided insufficient evidence to support their denial of payment. Therefore, we decided that the Plan has to 
reimburse you for the durable medical equipment provided on December 12, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an L4-5 decompression and fusion procedure. 
 
You asked the Plan to pre-approve an L4-5 decompression and fusion procedure. You say that the requested 
L4-5 decompression and fusion is medically necessary. The Plan denied your request. The Plan says the 
requested L4-5 decompression and fusion is not medically necessary. 
 
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 an L4-5 decompression and fusion 
procedure. Our reviewer says that the requested L4-5 decompression and fusion is not medically necessary. 
Our physician reviewer found the imaging studies do not show severe spinal stenosis or instability. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an L4-5 decompression and fusion procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an L4-5 decompression and fusion procedure.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
services are medically necessary. Our physician reviewer found clinical documentation shows that enrollee has 
benefitted from daily skilled services both therapy and skilled nursing, continues to have medical monitoring 
needs by a professional nurse as well as functional impairments. The care team states that the enrollee has not 
met all therapy/medical goals thus from a practical matter continued daily skilled services (nursing and 
therapy) appears to be medically necessary on an inpatient basis 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a general health panel provided to the enrollee on January 
26, 2022. 
 
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 excluded from Medicare payment. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for a general health panel 
provided to the enrollee on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on January 28, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care provided by an OON provider. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-
network care. 
 
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 subsequent nursing facility care provided on 
January 28, 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 genetic testing provided on January 30, 2022, billed with 
codes 81191, 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, and 81311. 
 
You asked the Plan to pay for the genetic testing billed. 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. 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 30, 2022, billed with codes 81191, 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, 
and 81311.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro power arm brace. 
 
You asked the Plan to pre-approve a MyoPro power arm brace. You say that the requested MyoPro power arm 
brace is medically necessary. The Plan denied your request. The Plan says the requested MyoPro power arm 
brace is not medically necessary. 
 
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 a MyoPro power arm brace. Our 
reviewer says that the requested MyoPro power arm brace is not medically necessary. Our physician reviewer 
found the powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double 
upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated (L8702) is not 
medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k). At this time the 
requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical 
condition/function of hemiparesis after stroke than any available standard therapy such as conventional 
treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional 
muscle strengthening, and Botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body 
member. The MyoPro is not known to be effective, based on scientific evidence, professional standards and 
expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is 
insufficient evidence in the literature that this device will increase participation in bimanual activities. 
 
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 MyoPro power arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro power arm brace.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics testing services provided on August 
9, 2021. 
 
You asked the Plan to pay for the lab services. You say that the testing is clearly medically necessary. The Plan 
denied your request. The Plan says one code must be submitted for the panel. 
 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 the testing panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the pharmacogenomics testing services provided on August 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on February 
24, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you only traveled 3 miles 
the cost shouldn't be that high. 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 $290 
copayment per date of service regardless of the number of trips.  
 
You have been asked to pay $290 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance Services 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 ambulance transport 
provided on February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services provided on March 31, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical pathology services. You say that you work with a group of doctors 
who are participating providers and use your laboratory exclusively. You say the enrollee does not go to the 
laboratory, so they are not using out-of-network benefits.  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 
surgical pathology services. We found no exception that would require the Plan to pay for the surgical 
pathology services. The records provided for review do not show that the surgical pathology services were 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for surgical pathology services 
provided on March 31, 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 genetic testing provided on February 2, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing was necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says the testing is statutorily 
excluded. 
 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 gene panel at issue includes the FANCC gene. Panels of tests 
that include this gene are statutorily excluded from coverage. 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 genetic testing provided on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for office visits and injections provided on 
February 16, 2022, to March 2, 2022. 
 
You asked the Plan to waive the cost share for office visits and injections. You say that you weren't charged 
this much last year. The Plan denied your request. The Plan says the cost share 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 all covered drugs and $25 copayment for a specialist office visit.  
 
 
 
 You have been asked to pay a total of $ 679.80 which is 20% of the allowed amount for the injections and the 
copayments for the office visits. The allowed amount for the injections is $3,024 (20% x $3,024 =$604.80). 
The copayment for the office visits is $75 ($25 x 3 visits). The injections fall within the Medicare Part B 
Prescription Drugs benefit category.  The office visit falls 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 cost share for office visits 
and injections provided on February 16, 2022, to March 2, 2022.