Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient rehabilitation services provided from August 11, 2021, to 
August 19, 2021. 
 
You asked the Plan to pay for inpatient rehabilitation services. You say that D1004 is a valid Case-Mix Group 
(CMG) code for the services provided. The Plan denied your request. The Plan says that this code was not 
billed appropriately. 
 
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 does not provide a clear argument as to why this specific 
code is not acceptable for the submitted claim. We have verified that D1004 is a valid Health Insurance 
Prospective Payment System (HIPPS) code for inpatient rehab services. The Plan does not state why the HIPPS 
code is wrong in this case, and no clear citation was provided to support the argument. Therefore, we decided 
that the Plan has to pay for inpatient rehabilitation services provided from August 11, 2021, to August 19, 
2021.  
 
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 pre-approve basic life support ambulance transportation. 
 
You asked the Plan to pre-approve basic life support ambulance transportation. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that ambulance transportation is covered when specific 
criteria are met.  
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 basic life support ambulance 
transportation. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
in this case, the record indicates that the enrollee was transported from acute care hospital to a skilled nursing 
facility. The record indicates that the enrollee was transported via stretcher. The record does not indicate that 
the enrollee's clinical condition is such that other methods of transport, such as stretcher van were 
contraindicated. The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 basic life support ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve basic life support ambulance transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on March 30, 
2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that this was routine lab work. 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 $0 
copayment for routine lab services and a $10 copayment for all others.  
 
The file shows that you were not charged for the routine lab work, however, the Vitamin D test is not 
considered routine. Therefore, you have been asked to pay a $10 copayment for the lab services. The lab 
services 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 laboratory services provided on March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
January 26, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 In this case, the CPT Code Manual definition of code 0037U is targeted genomic sequence analysis, solid organ 
neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, 
gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, 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 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on October 5, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that you are appealing the denied claim. The Plan 
denied your request. The Plan says the rendering provider is an OON provider and there was no referral from 
an in-network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
  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 home health visit provided on October 5, 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 the outpatient hospital services provided on October 4, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you are appealing the denied 
service. The Plan denied your request. The Plan says the rendering provider is an OON provider and there was 
no referral from an in-network provider or an approved authorization. Also, the service rendered was not urgent 
or emergent. 
 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 hospital services provided on 
October 4, 2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
February 13, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you left after a long wait without 
being seen by a doctor. 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 $90 
copayment for each visit for emergency services.  
 
The file shows that you were triaged and evaluated by the ER staff. Therefore, you have been asked to pay a 
$90 copayment for the ER visit. The ER visit falls within the Emergency Care 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 emergency room (ER) visit provided on February 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided on February 19, 2022. 
 
You asked the Plan to waive the copayment for lab work. You say that this should be free, or you will not 
continue to get these services done. 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 $5 
copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility).  
 
You have been asked to pay $5 copayment for lab work. Lab work 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 
lab work provided on February 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on February 28, 
2022. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you were unjustly dealt with so 
this should be covered. 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 $65 
copayment for each urgent care visit. 
 
You have been asked to pay $65 copayment for urgent care visit. Urgent care visits fall within the Urgently 
needed 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 urgent care visit provided 
on February 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on June 
29, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were informed 
that insurance would cover the cost. 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 $295 
copayment for each one-way ambulance trip.  
 
You have been asked to pay $223.52, which is less than the $295 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 June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you have an enlarged prostate with large stones 
accompanied by blood in your urine. You also say that you have a foley catheter and are in severe pain. You 
need to have surgery to relieve pressure as soon as possible. You have seen numerous doctors within the Plan 
and would like reconsideration to see the requested provider. The Plan denied your request. The Plan says you 
must see in-network providers to receive services with your Plan. 
 
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 (99204) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (84480, 80050, 84153) provided on April 
9, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you do not have access to the enrolle's 
information prior to the date of service. The Plan denied your request. The Plan says this was not authorized. 
 
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 (84480, 80050, 84153) 
provided on April 9, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve femoral-popliteal revascularization for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that that medical need has not been met for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. The patient has 
documented significant arterial occlusive disease of the left lower extremity. The physician correctly 
acknowledges that the patients walking symptoms are likely a combination of his vascular disease and lumbar 
spine disease. However, the patient is being scheduled for surgery on the left foot. It is reasonable and 
medically necessary to attempt to optimize blood flow to his left foot prior to the surgery. Our physician 
reviewer found that the enrollee's condition meets criteria for coverage of these services. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve femoral-popliteal revascularization for the enrollee.  
 
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 transport provided on February 
11, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that it was an emergency so it 
should be covered. 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 $255 
copayment for each one-way Medicare-covered ground trip.  
 
You have been asked to pay $255 copayment for ambulance transport. Ambulance transport 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 transport 
provided on February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L4-L5 epidural steroid injection services. 
 You asked the Plan to pre-approve the L4-L5 epidural steroid injection services. You say that the records 
provided support the need for the requested injection services. The Plan denied your request. The Plan says the 
clinical information does not describe the type of pain that allows for coverage of the requested injection 
services. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are covered for certain 
clinical indications. 
 
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 L4-L5 epidural steroid injection 
services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found an 
L4-L5 epidural steroid injection CPT 62323 is not medically necessary. The history and physical examination 
do not support a diagnosis of a lumbar radiculopathy. There is no evidence of a detailed neuromuscular exam 
with documentation of lower extremity strength, sensation or reflexes. There is no evidence of physical exam 
findings or a history of radiculopathy specific to the proposed area of the epidural injection. There is no 
evidence of post-laminectomy syndrome or acute herpes zoster associated pain. The documentation also does 
not reveal that the patient has the inability to tolerate noninvasive conservative care or medical documentation 
of failure to respond to four weeks of noninvasive conservative care or acute herpes zoster refractory to 
conservative management. There is no evidence of formal physical therapy for the lumbar condition. 
 
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 L4-L5 epidural steroid injection services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve L4-L5 epidural steroid injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on April 18, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you sent the medical records to support 
the services billed as medical necessity. The Plan denied your request. The Plan says the rendering provider is 
an OON provider and there was no referral from an in-network provider or an approved 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 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 specialist office visit provided on April 18, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a fitness membership provided on March 5, 2022. 
 
You asked the Plan to reimburse you for a fitness membership. You say that your plan will pay $200 per six 
months for joining a fitness center. The Plan denied your request. The Plan says this wellness center is not 
included in the fitness directory as an in-network fitness location and there were in-network fitness locations 
available to you. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because this wellness center is not included in 
the fitness directory as an in-network fitness location. Therefore, we decided that the Plan does not have to 
reimburse you for a fitness membership provided on March 5, 2022.