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

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on May 5, 2022. 
 
You asked the Plan to pay for diagnostic radiology services. The Plan denied your request. 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 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 diagnostic radiology services provided on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and the coinsurance for an eye exam, eye 
imaging and an aflibercept injection provided on May 16, 2022. 
 
You asked the Plan to waive the copayment and the coinsurance for an eye exam, eye imaging and an 
aflibercept injection. You say that you would like to have the diagnostics test cost sharing removed. The Plan 
denied your request. The Plan says you were 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 Medicare part B prescription drugs. Your contract with the Plan also says that you must pay a 
$48 copayment for all other physician services to diagnose and treat diseases and condition of the eye. Your 
contract with the Plan also says that you must pay a $75 copayment for diagnostic procedures and tests. 
 
You have been asked to pay a $48 copayment for an eye exam. An eye exam falls within the vision care benefit 
category. You have also been asked to pay $27, which is less than the $75 copayment for eye imaging. Eye 
imaging falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. You 
have also been asked to pay $362.75 in coinsurance, which is 20% of the allowed amount for an aflibercept 
injection ($1,813.77 allowed amount x 20% coinsurance = $362.75). An aflibercept injection falls within the 
Medicare Part B prescription drug 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 and 
the coinsurance for an eye exam, eye imaging and an aflibercept injection provided on May 16, 2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the CT of the abdomen and pelvis. We decided that the Plan does 
not have to pre-approve the CT of the chest.  
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan says that 
two sets of pictures (without a dye and then with a dye) are not needed. 
 
We decided that the Plan has to pre-approve the CT of the abdomen and pelvis.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 for the scan of the abdomen and pelvis. Our reviewer 
says that the requested imaging is medically reasonable and necessary.  Transplant patients are at increased risk of malignancy and more rapid progression of malignancy because of 
immunosuppression. Yearly screening CT scans are medically reasonable and necessary. A CT scan of the 
abdomen and pelvis without contrast material is considered medically reasonable and necessary for this 
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 been met. Therefore, we decided that the Plan has to pre-
approve the CT of the abdomen and pelvis.  
 
We also decided that the Plan does not have to pre-approve the CT of the chest. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 for a CT scan of the chest with and without contrast 
material. Our reviewer says that the documentation does not support that a CT scan of the chest with and 
without contrast material is medically reasonable in this case. A CT scan of the chest with contrast material, or 
a CT scan of the chest without contrast material should suffice. The provider can clarify whether a CT scan of 
the chest with contrast material, or a CT scan of the chest without contrast material is preferred. 
 
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 CT of the chest have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the CT of the chest. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87088, 87086, 81001, 87186) provided 
on March 30, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
  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 (87088, 87086, 81001, 87186) 
provided on March 30, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0089U, 81345) provided September 13, 
2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was 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 to report a Molecular Diagnostic Test service, 
providers must submit the appropriate DEX  Z-code. 
 
 
 
 
 We looked at the file and Medicare rules. An appropriate Z-code was not submitted with the claim. Based on 
this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for genetic testing (0089U, 81345) provided 
September 13, 2021.
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 the enrollee is currently stable for discharge from the inpatient hospital setting and daily 
skilled services are being requested in the acute rehabilitation setting. 
 
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 there is no medical complexity for physician supervision three times a week. There are no acute rehab nursing needs identified or documented. The enrollee does not need intensive 
therapies consisting of at least three hours of therapy per day, at least three hours of therapy per day, at least 
five days per week, with multidisciplinary approach in an IRF. The therapy that is needed is routine in a skilled 
nursing facility (SNF). An uncomplicated hip fracture does not require an IRF admission. The enrollee's rehab 
needs can be safely provided in a lower intensity and alternate setting such as in an SNF. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiovascular imaging to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON imaging. You say that the enrollee was seen and found to need a 
nuclear stress test to monitor his condition. This should be approved due to medical necessity. The Plan denied 
your request. The Plan says the enrollee was seen by an OON cardiologist without authorization. This imaging 
was ordered by the same OON provider. There are in-network cardiologists able to schedule the enrollee 
quickly and can provide the necessary services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
cardiovascular imaging to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical-necessity rules for the requested drug have not 
been met. 
 
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 Feraheme. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has a diagnosis of iron deficiency anemia. The Food and Drug Administration (FDA) has stated that 
the requested drug is indicated for the enrollee's condition. The record indicates that the enrollee has a 
hemoglobin level of greater than 13. The record provided does not support current iron deficiency. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Feraheme (Q0138).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with an urologist to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visit with a urologist. You say that the services should be covered 
as you disagree with the denial and would like to see the same provider. The Plan denied your request. The 
Plan says the services denied correctly as they are non-emergent and can be provided 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit with an urologist to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the copayment for Covid-19 testing kit on January 16, 2022. 
 
You asked the Plan to waive the copayment for Covid-19 test. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says that the cost sharing you are being charged is 
correct. 
 
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. Without the correct Evidence of Coverage (EOC), there is no way of knowing 
whether the copayment being charged is correct. Therefore, we decided that the Plan has to waive the 
copayment for Covid-19 testing kit on January 16, 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: Favorable

 
We decided that the Plan has to pre-approve computerized tomography (CT) scan of the thoracic spine with 
contrast material. 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says that a similar study that was requested was already approved and the 
provider did not confirm if the prior study was performed or not; therefore, the CT scan requested cannot be 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 the CT scan. Our reviewer says that the 
CT scan of the thoracic spine with contrast material is medically needed at this time. Our physician reviewer 
found that in this case the enrollee's CT scans have been ordered as part of a myelogram. This is a study that 
requires imaging of the entire spine for completion. In such a case, the CT of the thoracic spine would be 
reasonable and necessary in order to complete the specific imaging procedure/modalities. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve computerized tomography (CT) scan of the thoracic spine with contrast material.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 28, 2015. 
 
You asked the Plan to pay for the medical services. You say that the patient was enrolled at the time of service, 
so this claim should be paid. The Plan denied your request. The Plan says you did not timely file your claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services was not filed until May 18, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for medical services provided on April 28, 2015.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a chiropractor to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit with a chiropractor. You say that this provider says that his 
technique is completely different than the traditional chiropractors. You also say that since there is not a 
chiropractor who uses this technology in your network, you hope the Plan will reconsider the approval. The 
Plan denied your request. The Plan says there are other in-network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit with a chiropractor to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99401 billed for date of service October 21, 
2021. 
 
You asked the Plan to pay for procedure code 99401. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is non-covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
 We find that procedure code 99401 has a Status Indicator of N on the Physician Fee Schedule. This means that 
procedure code 99401 is not covered by Medicare. Based on this information, we decided that Medicare rules 
for coverage of procedure code 99401 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 99401 billed for date of service October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent trips. 
 
You asked the Plan to pre-approve additional non-emergent trips. You say that you need additional 
transportation to get you through to the end of the year. The Plan denied your request. The Plan says your 
benefit does not cover more than 30 one-way trips per plan year. 
 
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 a maximum of up to 30 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergent trips.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for a skilled nursing facility (SNF) stay from February 24, 2022, to March 
17, 2022. 
 
You asked the Plan to pay for a SNF stay. You say that the SNF services at issue were a medical necessity for 
you. The Plan denied your request. The Plan says that rules for payment have not been met because the 
occurrence code is missing or invalid on the billed claim. 
 
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. In this case, the Plan has denied payment for SNF services for a missing or 
invalid occurrence code. The Plan has not forwarded a copy of the claim to document that the occurrence code 
is missing or invalid. It is the Plan's responsibility to substantiate its denial. In this case, the denial has not been 
supported, so we must find in your favor. Therefore, we decided that the Plan has to pay for a SNF stay from 
February 24, 2022, to March 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.