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 January 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on January 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve destruction procedure provided on August 31, 
2022. 
 
You asked the Plan to pay for the nerve destruction procedure. You say that the website shows that no 
authorization is required for this service. The Plan denied your request. The Plan says that unauthorized, out-of-
network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the nerve destruction 
procedure provided on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 10, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
We are having difficulty getting ahold of the PCP for pre authorization. The Plan denied your request. The Plan 
says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SelectMDx genetic testing provided on March 29, 2022. 
 
You asked the Plan to pay for SelectMDx genetic testing. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  
The Plan must follow Medicare rules. Medicare rules say that NGS as a diagnostic laboratory test is reasonable 
and necessary and covered nationally when the criteria listed in the Medicare rules section of this letter have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SelectMDx genetic testing have not been met. Specifically, we determined that SelectMDx genetic 
testing does not have FDA clearance. Therefore, we decided that the Plan does not have to pay for SelectMDx 
genetic testing provided on March 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
September 01, 2022. 
 
You asked the Plan to waive the copayment for an electrocardiogram (ECG). You say that you feel that you 
should not owe anything for this service. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 $10 
copayment for in-network diagnostic procedures and tests, performed in a primary care physicians office. 
 
You have been asked to pay a $10 copayment for an electrocardiogram (ECG). This item/service falls within 
the in-network diagnostic procedures and tests, performed in a primary care physicians office 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 electrocardiogram (ECG) provided on September 01, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy biopsy provided on October 
19, 2022. 
 
You asked the Plan to waive the copayment for the endoscopy biopsy. You say that the services should have all 
been covered with a $0 copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $325 
copayment for outpatient surgery provided at an outpatient hospital facility.  
 
The records show you have not been charged for the screening colonoscopy. You have been asked to pay a 
$325 copayment for the endoscopy biopsy. This item/service falls within the outpatient surgery 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 endoscopy biopsy provided on October 19, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on September 14, 
2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that it is the responsibility of the facility 
to obtain referrals. The Plan denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary or rest home 
visit provided on September 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the intracardiac electrophysiological 
procedures provided on June 20, 2022. 
 
You asked the Plan to waive the copayment for the intracardiac electrophysiological procedures. You say that 
you were told this would be totally covered. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 for in-network outpatient surgery at an outpatient hospital facility. 
 
You have been asked to pay a $250 copayment for the intracardiac electrophysiological procedures. This 
item/service falls within the in-network outpatient surgery at an outpatient hospital facility 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 intracardiac electrophysiological procedures provided on 
June 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the pulmonary rehabilitation services 
provided from November 9, 2022, to November 29, 2022. 
 
You asked the Plan to waive the deductible for the pulmonary rehabilitation services. You say that you were 
told that these services would be covered. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 you must pay the full cost for covered services until you have paid the $750 
deductible, and the deductible applies to pulmonary rehabilitation services.  
 
 
 
 
 You have been asked to pay a $144.55 deductible for the pulmonary rehabilitation services ($28.91 allowed 
amount x 5 services = $144.55 deductible). The items or services you asked the Plan to waive the deductible 
for fall within the pulmonary rehabilitation services benefit category. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $750 deductible which applies to pulmonary rehabilitation 
services. This cost sharing is a contractual obligation that had not been met at the time the pulmonary 
rehabilitation services were provided from November 9, 2022, to November 29, 2022. Therefore, we decided 
that the Plan does not have to waive the deductible for the pulmonary rehabilitation services provided from 
November 9, 2022, to November 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
November 21, 2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that annual physical exams are 
covered with a $0 copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $10 
copayment for in-network outpatient lab services. 
 
You have been asked to pay a $10 copayment for the laboratory services. This item/service falls within the in-
network outpatient lab 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 
the laboratory services provided on November 21, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (88304, 88312, 88313, 88311) provided on June 
6, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the cost of these services is too expensive. 
The Plan denied your request. The Plan says that the claim is denied because no proof of payment was 
submitted. 
 
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 indicates that the claim is denied due to lack of proof of payment. 
However, the Plans EOC does not indicate that it is necessary for the enrollee to pay for the requested services 
in order for a claim to be processed. No further denial rationale or medical records were submitted for review. 
Thus, the Plan has not supported their denial of this claim. Therefore, we decided that the Plan has to pay for 
the laboratory services (88304, 88312, 88313, 88311) provided on June 6, 2022.  
 
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 c provided on September 16, 2022. 
 
You asked the Plan to pay for c. You say that computed tomography (CT)  of the chest without contrast The 
Plan denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for c provided on 
September 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy biopsy provided on October 
20, 2022. 
 
You asked the Plan to waive the copayment for the endoscopy biopsy. You say that you would like these 
charges waived. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $125 
copayment for in-network outpatient surgery at an ambulatory surgical center. 
 
You have been asked to pay a $125 copayment for the endoscopy biopsy. This item/service falls within the in-
network outpatient surgery at an ambulatory surgical center 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 endoscopy biopsy provided on October 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the high-tech muscle image provided on 
December 16, 2022. 
 
You asked the Plan to waive the copayment for the high-tech muscle image. You say that you did not have to 
pay for this test before. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 350 
copayment per day for Medicare-covered diagnostic radiology services, including myocardial perfusion 
imaging.  
 
You have been asked to pay a $350 copayment for the high-tech muscle image. This item/service 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 high-tech muscle image provided on December 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the review has determined that the record does not show that the enrollee's necessary hospital care would reasonably be expected to span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
November 15, 2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that this should not have a 
copayment because it was during an annual physical. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
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 $10 
copayment for outpatient laboratory tests. 
 
You have been asked to pay a $10 copayment for the laboratory services. This item/service falls within the 
outpatient laboratory tests 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 
laboratory services provided on November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management provided on December 06, 2022. 
 
You asked the Plan to pay for chronic care management. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chronic care 
management provided on December 06, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve a Vertiflex Superion Interspinous device. 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 a Vertiflex Superion Interspinous 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Vertiflex Superion interspinous spacer at the L4-5, in this case, is 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 a Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist visit provided on June 2, 
2022.  
 
You asked the Plan to reduce the copayment for the specialist visit. You say that your insurance card shows 
$35 for a specialist visit. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $45 
copayment per visit to a specialist.  
 
You have been asked to pay a $45 copayment for the specialist visit. This item/service falls 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 reduce the copayment for the specialist visit provided on June 2, 2022.