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

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
maxillofacial area and an otolaryngology specialist office visit provided on October 13, 2020. 
 
You asked the Plan to waive the copayment for a CT scan and a specialist office visit. 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 $150 
copayment for in-network diagnostic and nuclear medicine radiological services, including CT scans. The Plan contract also says that enrollees must pay a $30 copayment for an in-network specialist office visit. 
 
You have been asked to pay the allowed amount of $129.08, which is less than the $150 copayment for a CT 
scan. A CT scan falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. You have also been asked to pay a $30 copayment for a specialist office visit. A specialist office visit 
falls within the Physician/Practitioner Services, Including Doctors Office Visits. You have been asked to pay a 
total of $159.08 ($129.08 copayment + $30 copayment = $159.08).  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 a computed tomography (CT) scan of the maxillofacial area and an otolaryngology specialist 
office visit provided on October 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray of the chest (71045) provided on June 6, 2021. 
 
You asked the Plan to pay for an X-ray of the chest. You say that the claim at issue has been denied as a 
duplicate in error. The Plan denied your request. The Plan says rules for payment have not been met because 
the claim at issue is a duplicate of a prior claim that has been processed and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an X-ray of the chest have not been met. Specifically, the Plan has documented that the claim at 
issue is a duplicate of a prior claim that has been processed and paid. The available medical records do not 
support that a second instance of an X-ray of the chest was provided on the date of service. Therefore, we 
decided that the Plan does not have to pay for an X-ray of the chest (71045) provided on June 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray of the femur (73552) provided on June 4, 2021. 
 
You asked the Plan to pay for an X-ray of the femur. You say that the claim at issue has been denied as a 
duplicate in error. The Plan denied your request. The Plan says rules for payment have not been met because 
the claim at issue is a duplicate of a prior claim that has been processed and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an X-ray of the femur have not been met. Specifically, the Plan has documented that the claim at 
issue is a duplicate of a prior claim that has been processed and paid. The available medical records do not 
support that a second instance of an X-ray of the femur was provided on the date of service. Therefore, we 
decided that the Plan does not have to pay for an X-ray of the femur (73552) provided on June 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravascular ultrasounds (noncoronary vessel) (37253 
x2) provided on September 15, 2021. 
 
You asked the Plan to pay for the intravascular ultrasounds. You say that these services were billed 
appropriately. The Plan denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 37253 is intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the intravascular ultrasounds. Our reviewer says that these 
services are not supported as billed. Our reviewer found the operative report does not describe additional 
noncoronary vessel intravascular ultrasound, and therefore this procedure cannot be verified. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the intravascular ultrasounds have not been met. Therefore, we decided that the 
Plan does not have to pay for the intravascular ultrasounds (noncoronary vessel) (37253 x2) provided on 
September 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 21, 2021. 
 
You asked the Plan to pay for the services provided. You say that the documents support the codes billed on the 
claim. The Plan denied your request. The Plan says the screening panel does not meet Medicare coverage 
criteria. 
 
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. 
 
We looked at the file and the rules. We find that the cardiovascular gene panel was not ordered by the 
enrollees treating physician for a specific medical problem. Medicare does not cover this testing for screening 
purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on October 21, 
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 that both your neurologist and orthopedist doctors 
agree that you would benefit from IRF care. You say that you were quarantined for 8 days which has caused 
further delays with him getting the therapy he needs. The Plan denied your request. The Plan says authorization 
denied because the IRF care is not medically necessary, and your needs can be met at a lower level of care such 
as a skilled nursing facility (SNF). 
 
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 you are medically stable and do not need close physician supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic medical 
conditions. There were no acute nursing needs identified or documented. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis (81455) provided on 
December 29, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was requested directly from the 
treating physician who makes the professional determination of diagnosis and medical necessity to successfully 
treat the enrollee. The Plan denied your request. The Plan says enrollees must receive their medical services 
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with 
non-contracted providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis (81455) 
provided on December 29, 2021 by an out-of-network (OON) provider.
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 you need to start a rehabilitation program to return to 
prior level of functioning. You say that you are medically ready for discharge, but unable to go home. 
 The Plan denied your request. The Plan says authorization denied because the IRF care is not medically 
necessary, and your needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 you are medically stable and do not need close physician supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic medical 
conditions. You do not require 3 hours a day five days a week of IRF therapies with interdisciplinary 
management. The complexity of your medical and rehabilitation needs does not require an acute hospital 
inpatient rehabilitation stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the deductible applied for the hospital outpatient clinic visit (G0463) 
provided on January 25, 2022. 
 
You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the deductible has been applied correctly 
to the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $200 yearly deductible. The deductible does not apply to 
some services. This means that the Plan will pay their share of the costs for these services even if you havent 
paid your deductible yet. The deductible does not apply to specialist services. 
 
The Plan says you must pay a $149.23 deductible for the clinic visit provided by a specialist. Based on the Plan 
contract, however, you cannot be asked to pay more than a $0 deductible for specialist services. Therefore, we 
decided that the Plan has to waive the deductible applied for the hospital outpatient clinic visit (G0463) 
provided on January 25, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cardiologist services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve Cardiologist services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says There is no documentation 
received from the PCP that indicates any medical necessity for the member to be evaluated specifically by the 
cardiologist she is requesting. 
 
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 
Cardiologist services 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 the genetic testing provided on May 10, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test.  
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 genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
genetic testing provided on May 10, 2021.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at 
the current hospital and the LTACH would offer no additional services. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, conventional air services, transport, 
one way (A0431) and rotary wing air mileage (A0436) provided on December 16, 2021. 
 
You asked the Plan to pay for the air ambulance services. You say that the ambulance services were medically 
necessary. The Plan denied your request. The Plan says the ambulance services were not medically necessary.  
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the air ambulance services. Our reviewer 
says that the air ambulance services were not medically necessary. Our physician reviewer found the provided 
documentation does not support that the enrollee suffers from an illness or injury that contraindicates 
transportation by any means other than ambulance such as a stretcher van as they did not require treatment 
during transport. The reviewer found that the documentation does not support that the patient's condition was 
such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed 
a threat to the enrollee's survival or seriously endangered the enrollee's health. The reviewer also found that the 
documentation does support that the transferring hospital did not have adequate facilities to provide the medical 
services needed by the patient. No available orthopedic 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 the air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the ambulance service, conventional air services, transport, one way (A0431) and 
rotary wing air mileage (A0436) provided on December 16, 2021.
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 LTACH services. You say that LTACH services are medically necessary for 
you to regain maximum function. The Plan denied your request. The Plan says you are receiving the 
appropriate inpatient care at the current hospital and the LTACH would offer no additional services for you. 
 
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 that you do not require any services at the LTACH that are not available at the acute 
care hospital where you are currently receiving care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 waive the $300 cost share for a colonoscopy and pathology 
laboratory services provided on January 19, 2022. 
 
You asked the Plan to waive the $300 cost share for services rendered on January 19, 2022. You say that you 
called the Plan to ask if the procedure would be covered and you were assured it was. You also say there was 
no mention that there would be a copayment. The Plan denied your request. The Plan says you must pay a $290 
copayment for each Medicare-covered outpatient hospital facility visit. The Plan also says you must pay $10 
per day, per provider, for Medicare-covered lab services. 
 
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 $290 
copayment for outpatient hospital services. Your contract with the Plan also clearly says that you must pay   
$10 per day, per provider, for Medicare-covered lab services. You have been asked to pay a $290 copayment for a colonoscopy. A colonoscopy falls within the outpatient 
hospital 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.  
 
You have been asked to pay $10 for pathology laboratory services. Pathology laboratory 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 $300 cost share for services provided on 
January 19, 2022.