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

 
We decided that the Plan does not have to pay for lab services provided on May 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical records. 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 May 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on March 22, 2022. 
 
You asked the Plan to pay for outpatient services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for outpatient services provided on March 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for an out-of-network (OON) 
pacemaker insertion performed from February 11, 2022, to February 12, 2022. 
 
You asked the Plan to waive the deductible and coinsurance for the OON pacemaker insertion. You say that 
this was the only doctor who could perform the procedure. You say the procedure should be considered in-
network. The Plan denied your request. The Plan says the correct deductible and coinsurance was applied. 
 
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 $750 deductible which applies to certain items and services. 
 
Your contract with the Plan also clearly says that you must pay a 40% coinsurance for each outpatient hospital 
visit at an out-of-network (OON) facility. 
 
The pacemaker insertion falls within the benefit category Outpatient Surgery, Including Services Provided at 
Hospital Outpatient Facilities and Ambulatory Surgical Centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible which applies to certain items and services.  
 
The file shows that the Plan verified the provider is not a network provider. The file also shows that at the time 
of the procedure, you had $561.46 remaining to meet your deductible. This amount was applied first. The 40% 
coinsurance was then applied to the remaining allowed amount, for a total coinsurance of $3,760.12 ($9,961.77 
allowed amount - $561.46 deductible = $9,400.31 x 40% coinsurance = $3,760.12). The total for the deductible 
and coinsurance is $4,321.58. This cost sharing is a contractual obligation that had not been met at the time the 
OON pacemaker insertion was performed from February 11, 2022, to February 12, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible and coinsurance for an out-of-network (OON) 
pacemaker insertion performed from February 11, 2022, to February 12, 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 the enrollee is ready to transition to an 
LTACH and the records provided support the need for this level of care. The Plan denied your request. The 
Plan says the enrollee can receive the care needed at an alternate level of care. 
 
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 the enrollee appears to be stabilizing and tolerating weaning and should only require 
short-term additional acute care services that can be completed at the current facility until more appropriate for 
a lower level of care when close to baseline. The enrollee does not require services at the LTACH that are not 
already available at the current facility. Transfer to LTACH is not medically necessary at this time as it would 
not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drug on March 10, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drug. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost-sharing you are being charged 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 20% 
coinsurance for each Medicare-covered Part B drug. Provider billed in the amount of $683 and the allowed 
amount is $394.12. The Plan paid $315.30. $394.12 x 20% = $78.82. Therefore, result in the total cost-sharing 
amount of $78.82.  
 
You have been asked to pay a 20% coinsurance for Part B drug. Part B drug falls 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 Part B drug on 
March 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested Intracept intraosseous basivertebral nerve ablation at L3-4, 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit (99213) and destruction of premalignant 
lesions (17000 & 17003) provided on February 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit and destruction of premalignant lesions. You say that the 
services were processed in error under the group instead of the rendering provider. The Plan denied your 
request. The Plan says the services were provided out-of-network and were not approved in advance. 
  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 outpatient visit (99213) and destruction of 
premalignant lesions (17000 & 17003) provided on February 28, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device 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. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
  
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 8, 
2022, to March 10, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the enrollee improved with 48 hours. The Plan also says that the 
inpatient admission was not medically necessary. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would 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 pay for the acute inpatient hospital care provided from March 8, 2022, to March 10, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued oxygen equipment rental. 
 
You asked the Plan to pre-approve continued oxygen equipment rental. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is a capped rental item, and no additional payment 
can be made. However, the equipment is now considered to have been purchased. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no further payment for oxygen 
equipment during the 5-year reasonable useful lifetime (RUL) of oxygen equipment after 36 rental payments 
have been made. The supplier who provided the equipment during the 36th rental month is required to continue 
to provide the equipment, accessories, contents (if applicable), maintenance, and repair of the oxygen 
equipment during the 5-year reasonable useful lifetime of the equipment. 
 
We looked at the file and Medicare rules. The record shows that you have rented your equipment for 36 
months. No further rental payment can be made. However, the supplier of this equipment is required to 
continue to provide the equipment for the rest of its useful lifetime. Based on this information, we decided that 
Medicare rules for coverage of continued oxygen equipment rental have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued oxygen equipment rental.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for interferon injections provided from 
December 27, 2021, to February 7, 2022 . 
 
You asked the Plan to waive the coinsurance for interferon injections. You say that you feel these should be 
covered in full. The Plan denied your request. The Plan says the coinsurance applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each Medicare-covered Part B drug.  
 
You have been asked to pay 20% coinsurance to each date of service that interferon injections were 
administered. 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 interferon injections provided from December 27, 2021, to February 
7, 2022 .
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at-home COVID-19 test kits you purchased on January 16, 
2022. 
 
You asked the Plan to pay for the at-home COVID-19 test kits. You say that you were told you could submit 
these receipts for reimbursement. The Plan denied your request. The Plan says there is no coverage for at-home 
COVID-19 test kits purchased prior to February 1, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage plans may cover at-home 
COVID-19 test kits as a supplemental benefit starting January 15, 2022, or prior depending on the specific 
benefits offered by the Plan. In this case, your Plan did not offer a supplemental COVID-19 test kit benefit until 
February 1, 2022.  Your Plan's website specifically states that coverage for these tests kits is available for kits 
purchased between February 1, 2022, through December 31, 2022.  You purchased these test kits before 
coverage was available under your Plan. Based on this information, we decided that Medicare rules for coverage of the at-home COVID-19 test kits have not been met. Therefore, we decided that the Plan does not 
have to pay for at-home COVID-19 test kits you purchased on January 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the medication is necessary. The Plan denied your 
request. The Plan says routine costs associated with the clinical trial are not covered by the plan.  
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Keytruda as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 18, 
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 says non-urgent services should be from network providers who are contracted with 
the health plan and listed in the Provider Directory. 
 
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 laboratory services provided to the enrollee on 
March 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided on May 12, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
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 a pneumatic compression device provided on May 
12, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on 
February 9, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that your physician provided medically 
necessary services in good faith. The Plan denied your request. The Plan says non-emergent, non-urgent 
services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on February 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you need to see your doctor for surgery. 
You are requesting reconsideration for the additional mileage. The Plan denied your request. The Plan says you 
are requesting an additional 5 miles for a total of 55 miles and your benefit only allows 50 miles. The Plan also 
says you have exceeded your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 36 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
January 4, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file, and Medicare rules. The next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test 
(0037U) provided January 4, 2022.