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

 
We decided that the Plan does not have to waive the coinsurance for the radiopharmaceutical (code A9502) and 
saline (J7050) injections provided on March 3, 2022. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you were not told ahead of time 
that you would have a coinsurance. 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 20% 
coinsurance for Part B drugs injected during radiological services.  
 
You have been asked to pay $179.32, which is 20% of the allowed amount for the radiopharmaceutical 
($896.62 allowed amount x 20% = $179.32). You have also been asked to pay $0.14, which is 20% of the 
allowed amount for the saline infusion ($0.68 allowed amount x 20% = $0.14). Part B drug 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 the radiopharmaceutical (code A9502) and 
saline infusion (J7050) injections provided on March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the provider made the decision to send the patient's 
samples to your lab for processing, and these services were medically necessary. The Plan denied your request. 
The Plan says unauthorized, non-plan 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. 
 
Neither your lab nor the referring provider is a contract provider with the Plan. 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 lab services provided on April 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the computed tomography (CT) scan 
provided on May 1, 2022. 
 
You asked the Plan to waive the deductible for the CT scan. You say that you should not be separately charged 
for the it. You say it should be included with the services you received in the emergency room. 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. Your 
contract with the Plan says that there is a $5000 deductible which applies to outpatient diagnostic tests.  
 
 
 
 
 
 
 
 
 
 
 The record shows your CT scan was read by a different provider. The item or service you asked the Plan to 
waive the deductible for falls within the benefit category Outpatient Diagnostic Tests, Therapeutic Services and 
Supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $5000 
deductible which applies to outpatient diagnostic tests. This cost sharing is a contractual obligation that had not 
been met at the time the CT scan was received on May 1, 2022. Therefore, we decided that the Plan does not 
have to waive the deductible for the computed tomography (CT) scan provided on May 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you believe that LTACH care is needed. 
The Plan denied your request. The Plan says the enrollee's needs are being met at the current facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided on June 6 ,2022.  
 
You asked the Plan to pay for these services. You say that the Plan should pay for these services. The Plan 
denied your request. The Plan says you did not have prior authorization for 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 must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 
services provided on June 6, 2022 by Amy Glenn, NP.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on March 22, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you thought this was fully 
covered. 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 $100 for 
an ultrasound.  
 
You have been asked to pay $62.90, which is less than the $100 copayment for the ultrasound. The ultrasound 
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 ultrasound provided on March 22, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on February 23, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services are not billed correctly. 
 
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 references Local Coverage Determination (LCD) L35025 and Local 
Coverage Article (LCA) A56853 in their determination; however, these rules are not binding for the state of 
Massachusetts where the testing was performed. The Plan has not provided any Medicare rules or 
documentation to support the services are not payable as billed. Therefore, we decided that the Plan has to pay 
for the laboratory services rendered on February 23, 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 the ambulance services provided on May 3, 
2022, and May 7, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you pay a fee to your 
county fire and ambulance department, so you thought you would not be charged for ambulance trips. 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 $300 
copayment per one-way trip for ambulance transport.  
 
You have been asked to pay $250.86 for each trip, which is less than the $300 copayment for each ambulance 
service. Ambulance services fall 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 the ambulance services provided on May 3, 2022, and May 7, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on March 7, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services were not billed correctly. 
 
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 references Local Coverage Determination (LCD) L35025 and Local 
Coverage Article (LCA) A56853 in their determination; however, these rules are not binding for the state of 
Massachusetts where the testing was performed. The Plan has not provided any valid Medicare rules or 
documentation to support the services are not payable as billed. Therefore, we decided that the Plan has to pay 
for the laboratory services rendered on March 7, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fitness classes provided on January 1, 2022, to February 
28, 2022. 
 
You asked the Plan to pay for the fitness classes. You say that these services were reimbursed last year from 
the same gym. The Plan denied your request. The Plan says services provided by immediate relatives or 
members of your household are not covered under any condition. 
 
The Plan must follow Medicare rules. Medicare rules say that fees charged for care by your immediate relative 
or members of your household are not covered by the Plan under any condition..  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the fitness classes have not been met. Therefore, we decided that the Plan does not have to pay for 
the fitness classes provided on January 1, 2022, to February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 2, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 81162, 81323, and 81351 are not supported. 
 
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 81162 is BRCA1 (BRCA1, DNA repair associated), 
BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full 
sequence analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements). The 
definition of code 81323 is PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN 
hamartoma tumor syndrome) gene analysis; duplication/deletion variant. The definition of code 81351 is TP53 
(tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; full gene sequence. 
 
We find that CPT codes 81162, 81323, and 81351 are not supported in the medical record. Specifically, there 
are no submitted medical records for the billed date of service supporting that the laboratory services were 
performed.  Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for urgent care clinic services you received on 
October 3, 2021, and diagnostic testing you received on October 28, 2021, and November 6, 2021, at an 
outpatient hospital facility. 
 
You asked the Plan to waive the deductible for the outpatient hospital services. You say that these services 
were needed due to back pain.  You said that on these dates you were unable to walk due to pain. The Plan 
denied your request. The Plan says you had not yet met your deductible at the time of these services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to medical services.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which 
applies to medical services. This cost sharing is a contractual obligation that had not been met at the time the 
outpatient hospital services was received on October 3, 2021, to November 29, 2021. Therefore, we decided 
that the Plan does not have to waive the deductible for urgent care clinic services you received on October 3, 
2021, and diagnostic testing you received on October 28, 2021, and November 6, 2021, at an outpatient 
hospital facility.  
 Your complaint about the Plan asking you for updated information is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular screening provided to the enrollee on October 
6, 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 Medicare covers lipid panel testing as cardiovascular screening once every 5 years and denies coverage for all cardiovascular genetic risk assessment panels for patients with suspected or documented 
cardiovascular disease. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the services, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
cardiovascular screening provided to the enrollee on October 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network testing services provided to the enrollee on 
February 1, 2022. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 testing services provided to the 
enrollee on February 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) 
provided on April 8, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you could not have all 3 MRIs on the 
same day due to your condition. You say you would like this copayment waived. 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 $225 
copayment for each advanced imaging service, including MRIs.  
 
 
 
 
 
 You have been asked to pay $213.85, which is less than the $225 copayment for the MRI. An MRI falls within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the magnetic resonance imaging (MRI) provided on April 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ER visit provided on May 21, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you shouldn't be billed for the 
hospital visit because the wait time was 2.5 hours. You say that the nurse only wrapped your finger in gauze 
and referred you to another location for a hand specialist. 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 a $90 
copayment per emergency room visit within or outside the service area.  
 
You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within Emergency care 
Worldwide Emergency/Urgent Coverage 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 ER visit provided on May 21, 2022.  
 Your complaint about the hospitals inability to treat your injury and wait time is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of right 
femoral neck fracture on January 27, 2022 with osteopenia on bone density testing from December 16, 2020. 
Based on the medical records provided and the Medicare-approved major drug compendia there is no 
documentation that Evenity meets Medicare criteria for safe and effective. Clinically the patient does have 
osteoporosis; however, Evenity is Food and Drug Administration (FDA)-approved for the treatment of 
osteoporosis in postmenopausal women at high risk for fracture. It is not approved, and it has no off-label 
indication for treatment of osteoporosis in males. 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Evenity.