Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for aflibercept injections provided from 
January 9, 2020, to March 10, 2020. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you were not informed of the 
coinsurance at the times of service. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
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 20% 
coinsurance for each Part B drug. 
 
 
 
 Drug Allowed Amount 20% Coinsurance 
Aflibercept  January 9, 2020 $3,809.88 $761.98 
Aflibercept  February 12, 2020 $3,809.88 $342.05* 
Aflibercept  March 10, 2020 $3,809.88 $761.98 
Total:  $1,866.01 
 
* Note  This amount is lower due to meeting your maximum out-of-pocket (MOOP) expenses for the year. 
Amounts are applied to your maximum in the order in which the claims are received and processed by the Plan. 
 
You have been asked to pay $1,866.01, which is less than 20% coinsurance for the injections, due to meeting 
your MOOP for the year. The injections fall within the Medicare Part B Prescription Drugs benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for aflibercept injections provided from January 9, 2020, to 
March 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the current level of function, the enrollee does not require an intensive, 
complex, multidisciplinary approach to daily therapy. 
 
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 the enrollee does not require the intensity of services provided at an IRF.   Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of 
rehabilitative services with regular physician evaluation.  The enrollees care needs can be met at a lower 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out-of-network podiatry services received on January 25, 
2022. 
 
You asked the Plan to pay for the services. You say that you started to have extreme pain and went to urgent 
care. The Plan denied your request. The Plan says there is no evidence of that removal of skin lesions by a 
podiatrist would have been urgent 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 out-of-network podiatry services received on 
January 25, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an office visit provided on February 17, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you feel these bills should be 
covered because you are on a zero-copay low-income policy. The Plan denied your request. The Plan says that 
the copayment applied is correct. 
 
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 enrollees must pay $0 copayment for primary care office visits. 
 
The Plan says you must pay $29.24 copayment for an office visit. Based on the Plan contract, however, you 
cannot be asked to pay more than $0 copayment for an office visit. Therefore, we decided that the Plan has to 
waive the copayment for an office visit provided on February 17, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
February 1, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you are not satisfied 
with the service provided. 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 for each one-way ambulance trip.  
 
You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation 
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 transportation provided on February 1, 2022.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for subsequent hospital care provided on January 27, 2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that the Plan is responsible for payment. The 
Plan denied your request. The Plan says that Hospice was the primary and responsible payer per Medicare 
guidelines. 
 
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 has not provided us with proof of Hospice enrollment. 
Therefore, we decided that the Plan has to pay for subsequent hospital care provided on January 27, 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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the at-home coronavirus test kit purchased on January 21, 2022. 
 
You asked the Plan to pay for the at-home coronavirus test kit. You say that you feel you should be reimbursed 
for the at-home test kits. The Plan denied your request. The Plan says that coverage for at-home tests was not in 
effect on the date of service in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that plans and insurers are required to cover at-home 
over-the-counter COVID-19 tests purchased on or after January 15, 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at-home coronavirus test kit have been met. Therefore, we decided that the Plan has to pay for 
the at-home coronavirus test kit purchased on January 21, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing home discharge services provided on 
August 10, 2021. 
 
You asked the Plan to pay for nursing home discharge services. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 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 nursing home discharge services provided on 
August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (0242U) 
provided on February 8, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Guardant360 CDx. You say that the test order form demonstrates that the 
enrollee meets the ordering criteria set forth in the NCD. The enrollee has advanced cancer and is looking to 
undergo further therapy. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
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 targeted genomic sequence analysis panel 
(0242U) provided on February 8, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic mammogram provided on 
March 17, 2022. 
 
You asked the Plan to waive the copayment for mammogram. You say that you did not receive this type of bill 
last year when you had the procedure done. You also feel you do not owe it because its a yearly exam. The 
Plan denied your request. The Plan says the copayment applied is correct. The copayment is correct because 
there is a history of breast cancer which makes this a diagnostic exam and not a screening. 
 
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 $35 
copayment for per day, per provider, for Medicare-covered x-ray services.  
 
 
 
 
 You have been asked to pay $35 copayment for mammogram. Diagnostic mammograms 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 diagnostic mammogram provided on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial observation care (99220) and the observation care 
discharge day management (99217) provided from December 23, 2021, through December 24, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable, as the enrollee 
has other insurance as their primary insurance carrier. Additionally, the primary insurer must be billed first 
before payment can be issued for denied services.  
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers.  Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill 
directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the 
primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary 
insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has spoken with 
the providers office and confirmed they will bill the primary insurer directly. As the secondary insurer, the 
Plan cannot be held responsible for these services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the initial observation care (99220) and 
the observation care discharge day management (99217) provided from December 23, 2021, through  
December 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0481) provided to the enrollee on 
February 11, 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 the medical records do not contain documentation for definitive laboratory results of 8 to 14 drug 
classes. 
 
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 G0481 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed." 
 
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 while multiple drugs were tested, 
these drugs can be grouped into 4-6 classes. As such, billing for the testing of 8-14 classes is not supported. 
 
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 drug testing services (G0481) provided to the enrollee on February 11, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on January 20, 2022. 
 
You asked the Plan to pay for subsequent hospital care. The Plan denied your request. The Plan says the 
member was effective with hospice and Traditional Medicare would be the responsible payer per Medicare 
guidelines. 
 
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 subsequent hospital care provided on January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88341, 88342, 88360, 88381) provided May 27, 
2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88341, 88342, 88360, & 88381 is not supported in the medical record. Specifically, 
these services have a professional component / technical component identifier of 1 and were billed in the 
hospital setting. A required modifier was not included. 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 lab services (88341, 88342, 88360, 88381) provided May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis panel provided to the 
enrollee on November 9, 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 there is unproven clinical efficiency of liquid biopsy in renal cell cancer management. 
 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the clinical documentation does not support that the enrollee was not previously tested using the 
same NGS test for the same primary diagnosis of cancer, and has decided to seek further cancer treatment for 
which the testing would impact management of the enrollee. 
 
We looked at this physician'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 a targeted genomic sequence analysis panel provided to the enrollee on November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this injection was recommended until surgery 
can take place. The Plan denied your request. The Plan says there is no documentation that supports the request 
for another injection at this time. 
 
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 the injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this request exceeds the utilization criteria of no more than 4 injection sessions per section of the 
spine within a 12 month period. 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on January 30, 
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 the patient was enrolled in hospice. 
 
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 ambulance services provided to the enrollee on January 30, 
2022.