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

 
We decided that the Plan does not have to pay for lab services provided on August 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
August 26, 2021, to August 30, 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 DRG and secondary diagnosis were not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 180 (RESPIRATORY NEOPLASMS WITH 
MCC). 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 pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
review indicates that the documentation supported an admission for malignant neoplasm of upper lobe, right 
bronchus or lung. While acute respiratory Failure with hypoxia was noted to be documented under the hospital 
diagnoses:hospital problems in the discharge summary, supporting medical record documentation was not 
found within the record. This diagnosis is not clinically validated. DRG 181: RESPIRATORY NEOPLASMS 
WITH CC is the appropriate DRG in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from August 26, 2021, to August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99219), provided on September 19, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service should be covered. The Plan denied your 
request. The Plan says services were obtained by an out-of-network 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 the office visit (99219), provided on September 
19, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit and inpatient stay provided from 
January 7, 2022, to January 12, 2022. 
 
You asked the Plan to waive the copayment for ER visit and inpatient stay. You say that you should not be 
charged an inpatient stay 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 $90 
copayment for ER visit and $250 copayment per day, for days 1 through 6 admission.  
 
 You have been asked to pay a $90 copayment for the ER visit and $1,250 copayment for the inpatient stay 
($250/day x 5 days = $1,250). The total amount you owe is $1,340 ($90 + $1,250 = $1,340). ER visit falls 
within the Emergency care benefit category and 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 ER visit and inpatient stay provided from 
January 7, 2022, to January 12, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan does not have to waive the copayment for a physical therapy visit provided on 
January 12, 2022. 
 
You asked the Plan to waive the copayment for a physical therapy visit. You say that you did not have physical 
therapy after your surgery. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 did not provide medical records to show if a physical therapy visit took 
place. Without the medical records we are unable to determine if the cost sharing amount applied is correct. 
Therefore, we decided that the Plan does not have to waive the copayment for a physical therapy visit provided 
on January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression wrap identified with code E1399. 
 
You asked the Plan to pre-approve the compression wrap. You say that the requested item is medically 
necessary. The Plan denied your request. The Plan says the requested service is not covered by Medicare or the 
plan. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code E1399 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression wrap identified with code 
E1399.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on February 16, 
2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you were told there would be no 
charge. 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 $10 
copayment per day, per provider, for Medicare-covered lab services.  
 
You have been asked to pay $10 copayment for lab services. Lab services 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 lab services provided on February 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the requested services are medically 
necessary. You say that the enrollee reports decreasing hip pain and increased strength with PT. You also say 
that the enrollee is demonstrating improvement. The Plan denied your request. The Plan says the requested PT 
visits are not medically necessary. 
 
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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the provided documentation indicates that the enrollee has previously 
been treated with outpatient therapies and should be independent with a home exercise program. The reviewer 
found there is no documentation of a recent injury or decline in function. The reviewer found that additional 
therapy services are not an appropriate duration and frequency for treatment of the enrollees medical condition 
and therefore are 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 additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 12 additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vacuum pump addition to lower limb prosthesis 
(VASS). 
 
You asked the Plan to pre-approve VASS. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested item 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 VASS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has had a recent replacement socket. The requested device has not been shown to 
be superior to other standard treatments for the medical condition. Therefore, the enrollee does not meet criteria 
for the requested item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VASS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve vacuum pump addition to lower limb prosthesis (VASS).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for air ambulance services provided on October 30, 2021. 
 
You asked the Plan to pay for the air ambulance services. You say that this transport was medically necessary 
because the patient required intensive care and there were no beds available at the hospital where the patient 
departed from. The Plan denied your request. The Plan says that non-emergency ambulance is 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. Specifically, the Plan's sole rationale for denial is that non-emergency 
ambulance is not covered.  This is not true.  Plans are required to cover at least as much as Original Medicare.  
Original Medicare DOES cover non-emergency ambulance services in certain scenarios.  Furthermore, the 
Plan's own Evidence of Coverage explicitly states "non-emergency transportation by ambulance is appropriate 
if it is documented that the member's condition is such that other means of transportation could endanger the 
person's health and that transportation by ambulance is medically required." Clearly, non-emergency 
ambulance is a covered benefit.  The Plan has made no argument or provided any proof or documentation that 
the patient did not meet coverage criteria for these ambulance services.  The burden is on the Plan to support its 
denial, and it has failed to do so in this case. Therefore, we decided that the Plan has to pay for air ambulance 
services provided on October 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOneCDx testing services provided on December 
9, 2021. 
 
You asked the Plan to pay for the FoundationOneCDx testing services. You say that the records provided 
support the services in dispute. The Plan denied your request. The Plan says testing for the FANCC genes is not 
a Medicare benefit and is statutorily excluded. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene will 
be denied.  
 
We looked at the file and Medicare rules. The records show that the FoundationOneCDx testing services 
included the FANCC gene. 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 FoundationOneCDx testing services 
provided on December 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 11, 2020. 
 
You asked the Plan to pay for the lab services. You say that you believe you filed this claim timely. The Plan 
denied your request. The Plan says you did not timely file your claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed with the Plan until December 17, 2021.  It 
appears that you may have filed this claim with another insurer in April of 2020. This means that more than one 
calendar year from the date of service had passed before a claim was filed with this Plan. Therefore, we 
decided that the Plan does not have to pay for lab services provided on April 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response provided on December 4, 2021. 
 
You asked the Plan to pay for this transport. You say that this bill should be paid by the Plan. The Plan denied 
your request. The Plan says ambulance response with no transport is not covered by Medicare. 
 
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 December 4, 2021. 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 ambulance response 
provided on December 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 addition physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 10 addition PT visits. You say that the additional visits are medically 
necessary to establish a home program. The Plan denied your request. The Plan says the additional PT visits are 
not medically necessary. 
 
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 10 addition PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the provided documentation indicates that the enrollee has had prior 
therapy. The reviewer found the documentation does not reveal that the enrollee's functional level requires the 
unique skills of a professional therapist to safely and effectively provide treatment, that the services can be 
safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The 
requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of 
a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's 
current condition or to prevent or slow further deterioration. Therefore, the reviewer found that the requested 
additional PT visits are 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 10 addition PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 addition physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Octagam. 
 
You asked the Plan to pre-approve Octagam. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Octagam. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found in this case, 
intravenous immunoglobulins (IVIG) is not FDA-approved for the treatment of distal axonal sensory 
polyneuropathy. The use of Octagam is not supported by major drug compendia or by the medical literature. 
Peripheral neuropathy from multiple myeloma not associated with amyloid or POEMS (Polyneuropathy, 
Organomegaly, Endocrinopathy, Monoclonal gammopathy and Skin abnormalities) is unusual. The service is 
not reasonable or 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 Octagam have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Octagam.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services provided on October 21, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the patient was transported multiple times 
on this date of service. The Plan denied your request. The Plan says that this claim is a duplicate. 
 
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. Specifically, the Plan's sole denial rationale is that the claim is a duplicate.  
However, you provided multiple trip reports showing that the patient was transported multiple times on this 
same day.  The Plan has failed to acknowledge this or provide any argument at all as to why the multiple trip 
reports were not considered.  The burden is on the Plan to show that its denial was appropriate.  The Plan has 
failed to do so here by failing to even comment on the multiple trip reports. Therefore, we decided that the Plan 
has to pay for ambulance services provided on October 21, 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: Other
Decision: Favorable

 
We decided that the Plan has to pay for emergency room services (99285) provided August 3, 2021. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says that the claim is a duplicate. 
 
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. No records were provided to show that this claim was a duplicate. Claim 
numbers were not provided. Therefore, we decided that the Plan has to pay for emergency room services 
(99285) provided August 3, 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.