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

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit, and hearing tests provided 
on December 13, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hospital outpatient clinic visit and hearing tests. You say that the enrollee was 
told his plan was national and was not aware the claim would be processed as out-of-network. You say the 
services were medically necessary and you were unaware an authorization was needed. The Plan denied your 
request. The Plan says no prior authorization was 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 did not pre-approve the 
hospital outpatient clinic visit and hearing tests. We found no exception that would require the Plan to pay for 
the hospital outpatient clinic visit and hearing tests. The records provided for review do not show that the 
hospital outpatient clinic visit, and hearing tests were urgent or emergent. Therefore, we decided that the Plan 
does not have to pay for the hospital outpatient clinic visit, and hearing tests provided on December 13, 2021, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by on 
November 29, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were never told that 
you had to pay a separate copayment following surgery. The Plan denied your request. The Plan says they 
confirmed with the enrollee's call records that they were advised of the correct copayment; therefore, the proper 
copayment was applied for the service that was rendered. 
 
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 $325 
copayment per admission for each medically necessary inpatient stay.  
 
  You have been asked to pay a $325 copayment for an inpatient hospital stay. An inpatient hospital stay falls 
within the Inpatient hospital 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 inpatient hospital stay provided by on November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing provided on February 21, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined that testing for 
the FANCC is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, 
MolDX will also deny panels of tests that include the FANCC gene.  
 
We looked at the file and Medicare rules. Per LCA A53628, the requested FANCC genetic testing is not a 
covered benefit. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the FANCC genetic testing provided on 
February 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve delivery of home meals (S5170). 
 
You asked the Plan to pre-approve delivery of home meals. You say that you would like the meal deliveries 
covered. The Plan denied your request. The Plan says the Plan's criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that home delivery of meals may be covered as a 
supplemental benefit. The Plans contract specifies that the supplemental benefit for meals will be covered 
following an enrollees discharge from a hospital due to congestive heart failure.  
 
We looked at the file and Medicare rules. In this case, the documentation does not indicate you have a history 
of congestive heart failure. Based on this information, we decided that Medicare rules for coverage of delivery 
of home meals have not been met. Therefore, we decided that the Plan does not have to pre-approve delivery of 
home meals (S5170).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (U0004) provided August 7, 2020. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is included in payment to the facility and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that COVID-19 testing performed during a covered 
skilled nursing stay is subject to skilled nursing facility bundled billing and is not separately payable. 
 
We looked at the file and Medicare rules. This service was performed during a covered skilled nursing stay. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (U0004) provided August 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pharmacogenetic testing coded with 81401, 
81225, 81227, 81226, 81240, 81241, 81291, 81335, 81355 provided March 22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you have attached the documents that 
supports the CPT's/ICD's billed on the claim. Kindly review and reprocess the claim towards payment. 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, we find that the CPT codes are not supported in the medical record. Specifically, Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be 
considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be 
submitted for the panel]. 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 
molecular pharmacogenetic testing coded with 81401, 81225, 81227, 81226, 81240, 81241, 81291, 81335, 
81355 provided March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement services provided on January 5, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for debridement services. You say that the provider relies on facility staff to verify 
eligibility and obtain authorization from the enrollee's insurance company. The Plan denied your request. The 
Plan says no prior authorization was 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 did not pre-approve the 
debridement services. We found no exception that would require the Plan to pay for the debridement services. 
The records provided for review do not show that the debridement services were urgent or emergent. 
Therefore, we decided that the Plan does not have to pay for debridement services provided on January 5, 2022, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI for the enrollee. 
 
You asked the Plan to pre-approve an MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that an MRI is not medically necessary as the wound is chronic and preliminary testing 
to identify underlying cause of ulcer persistence has not been done. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our reviewer says that an MRI 
is not medically reasonable and necessary. There is no updated x-ray and no clinical evidence to support the 
medical necessity of this service. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for an MRI. 
 
 
 
 
 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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an MRI for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography services (93308, 93321, 93325) provided 
on January 20, 2022. 
 You asked the Plan to pay for echocardiography services. You say that you have provided records to support 
the services billed. The Plan denied your request. The Plan says rules for payment have not been met because 
the services at issue are included in another billed code. 
 
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, we have confirmed that codes 
93308, 93321, and 93325 are column II codes to column I code 33361. This claim has not been billed with 
appropriate modifiers to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for echocardiography services (93308, 93321, 
93325) provided on January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82310, 82728, 83540, 83550, 83970, 84100) 
provided November 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
lab services (82310, 82728, 83540, 83550, 83970, 84100) provided November 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis; with contrast (74177) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the enrollee has stage 4 
lung cancer and the sooner the CT scan is done the sooner they can do treatment planning. The Plan denied 
your request. The Plan says care must be received from a network provider. The Plan also says there are in-
network providers available to perform the requested CT scan. 
 
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 
a computed tomography (CT) scan of the abdomen and pelvis; with contrast (74177) to be provided by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses (V2599) provided on July 25, 2021. 
 
You asked the Plan to pay for contact lenses. You say that you were told by the Plan that you had vision 
benefits in 2021, and you feel this claim should be processed and paid. You state that the Plan agrees that you 
were given incorrect information. The Plan denied your request. The Plan says your plan does not cover 
eyewear except for standard lenses and frames provided after cataract surgery in which the lens of the eye was 
removed. Eyewear (frames and lenses or contact lenses) in order to improve vision is not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. In addition, the 
documentation provided by the Plan indicates that you were only given incorrect information in December of 
2021, which is after these services were provided. The Plan also cites another call in December 2021, where 
you were given correct information that you did not have vision benefits in 2021. It does not appear that the 
information given by the Plan affected your choice in care as this information was not provided before services 
were received. Therefore, we decided that the Plan does not have to pay for contact lenses (V2599) provided on 
July 25, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the deductible for anesthesia provided on December 21, 2021. 
 
You asked the Plan to pay for the deductible for anesthesia. You say that this charge should be covered. The 
Plan denied your request. The Plan says that the deductible applied 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. The Plan says the claim was paid toward the in-network benefit level. The Plan 
did not submit documentation showing how much was paid on the claim or what in-network benefit was 
applied. This means we cannot determine that the claim was processed correctly. It is the burden of the health 
plan to substantiate their decision with evidence. In this case, their decision has not been substantiated. 
Therefore, we decided that the Plan has to pay for the deductible for anesthesia provided on December 21, 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided 
from December 19, 2021, through December 31, 2021. 
 
You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee has exhausted the allowable 
benefit for this service. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 29, 2021, 
through December 18, 2021. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period.  The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a 
hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have 
to pay for the inpatient skilled nursing facility (SNF) care provided from December 19, 2021, through 
December 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient surgery services provided on 
October 20, 2021, to October 21, 2021. 
 
You asked the Plan to waive the coinsurance for outpatient surgery services. You say that when you had the 
other knee surgery done a few months ago and the cost was much cheaper, and you don't think it should be this 
much now. 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 30% 
coinsurance for each surgical or observation room service you get at an outpatient hospital.  
 
 
 
 You have been asked to pay $4,057.84 which is 30% of the allowed amount for outpatient surgery services. 
The allowed amount is $13,526.12(30% x $13,526,12=$4,057.84). Outpatient surgery services fall 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. Therefore, we decided that the Plan does not have to waive the coinsurance for outpatient 
surgery services provided on October 20, 2021, to October 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cystourethroscopy (52330) and cystourethroscopy with 
ureteroscopy (52344) provided on February 14, 2022. 
 
You asked the Plan to pay for the cystourethroscopy (52330) and cystourethroscopy with ureteroscopy (52344). 
You say that these codes are separately payable per NCCI edits. You say that the medical records should be 
reviewed, and the codes reconsidered for reimbursement. The Plan denied your request. The Plan says 
procedure codes 52330 and 52344 are considered inclusive to procedure code 52356. 
 
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, we have confirmed that codes 52330 and 52344 are column II codes to column I code 52356; 
however, 52330 and 52344 were billed with a modifier.  
 
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 cystourethroscopy (52330) and cystourethroscopy with 
ureteroscopy (52344). Our reviewer says that the documentation submitted was reviewed and does not meet the 
criteria for coverage. Our reviewer found the operative report describes procedures performed on the left side. 
In this case, modifier -59 is not supported and these procedures would not be reported separately. 
 
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 cystourethroscopy (52330) and cystourethroscopy with ureteroscopy 
(52344) have not been met. Therefore, we decided that the Plan does not have to pay for the cystourethroscopy 
(52330) and cystourethroscopy with ureteroscopy (52344) provided on February 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a subcutaneous cardiac rhythm monitor 
including programming (33285) 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 the enrollee has not had any syncopal episodes. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The patient has no 
history of atrial fibrillation, nor were any significant cardiac arrhythmias noted on ECG monitoring. A recent 
randomized clinical trial found that continuous monitoring for atrial fibrillation with an ILR (followed by 
treatment with oral anticoagulation if atrial fibrillation was detected) was not superior to usual care in reducing 
stroke or systemic embolism among patients at high risk of stroke but without a known prior history of atrial 
fibrillation. At this time, insertion of an ILR would not be considered medically appropriate and necessary in 
this patient's clinical management. Our physician reviewer found that the enrollee's condition does not meet 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of a subcutaneous cardiac rhythm monitor including programming (33285) 
for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walk-in tub provided April 24, 2022. 
 
You asked the Plan to pay for a walk-in tub. You say that before COVID you went to water aquatics, and it 
worked well for you. You want to stay in the home as much as possible due to COVID and sickness. You 
cannot get into a typical bathtub and the jets provide pain relief. The Plan denied your request. The Plan says 
this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for a walk-in tub provided April 24, 2022.