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

 
We decided that the Plan does not have to waive the deductible for laboratory services and the 
electrocardiogram provided on April 6, 2022. 
 
You asked the Plan to waive the $25.71 deductible for laboratory services and the electrocardiogram. You say 
that you should not be responsible for this because this was part of your Annual Wellness Visit. The Plan 
denied your request. The Plan the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 which applies to laboratory services and the electrocardiogram.  
 
The items or services you asked the Plan to waive the deductible for fall within the benefit Outpatient 
Diagnostic Tests and Therapeutic Supplies. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $500 deductible which applies to laboratory services and non-radiological diagnostic 
services  This cost sharing is a contractual obligation that had not been met at the time laboratory services was 
received on April 6, 2022. Therefore, we decided that the Plan does not have to waive the deductible for 
laboratory services and the electrocardiogram provided on April 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on January 20, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you want the Plan 
to pay for this service. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 20, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on January 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria under Center for Medicare and Medicaid Services guidelines. The Plan denied your request. The Plan 
says the admission to LTACH was denied as not meeting criteria, is not medically necessary, and continued 
acute hospital stay was offered. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the current acute care setting. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they 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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of inpatient 
rehabilitation admission. The Plan denied your request. The Plan says based on Medicare guidelines and the 
information we have about your condition you do not meet the requirements for approval. 
 
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 were admitted for aortic valve replacement and aortic aneurysm repair. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.  While you have a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. Medically necessary care can be provided in a different level of 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 the IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 there are no services available at the LTACH that you require that are not available at 
the health care setting being offered by the health plan. The health plan has approved ongoing care in the 
current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polycarbonate or equal lens (V2784) and anti-reflective 
coating (V2750) provided on December 10, 2021. 
 
You asked the Plan to pay for the polycarbonate or equal lens and anti-reflective coating. You say that the 
vision center told you they would fix the claim because they charged you for a standard frame, and you were 
supposed to be charged for deluxe frames so they would be covered. The Plan denied your request. The Plan 
says you are responsible for $165 for the upgraded lenses you received. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The contract clearly states that any additional upgrades to the select 
pair of glasses will be at your cost. Polycarbonate or equal lenses and anti-reflective coating are considered to 
be upgrades. Based on this information, we decided that the Plan's rules for coverage of the polycarbonate or 
equal lens and anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to 
pay for the polycarbonate or equal lens (V2784) and anti-reflective coating (V2750) provided on December 10, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve neuropsychological testing. You say that neuropsychological testing is 
medically necessary. The Plan denied your request. The Plan says neuropsychological testing does not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 neuropsychological testing. Our 
reviewer says that neuropsychological testing is not medically necessary. Our physician reviewer found that the 
provided records do not document that abnormalities of brain function are present or suspected in this case as is 
required by the Local Coverage Determination (LCD): Psychological and Neuropsychological Testing - 
L34646.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presbyopia correcting function of intraocular lens (P-C 
IOL) (V2788) provided on April 6, 2022. 
 
You asked the Plan to pay for the P-C IOL. You say that it is your understanding that you have coverage for 
this procedure when a basic mono-focal lens is implanted, but not when a multi-focal lens is implanted. You 
also say that the procedure is the exact same regardless of which lens is implanted. The Plan denied your 
request. The Plan says this service is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL.  
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for the presbyopia correcting 
function of intraocular lens (P-C IOL) (V2788) provided on April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee can be treated in the current setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 18, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 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 reduce the copayment for the outpatient office visit with an 
ophthalmologist (99214) provided on February 8, 2022. 
 
You asked the Plan to reduce the copayment for the outpatient office visit. You say that this bill should be $15, 
and not $28. The Plan denied your request. The Plan says an answer was not provided to you within 60 
calendar days after receiving your request. 
 
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 $32 
copay for each visit to a specialty physician office.  
 
You have been asked to pay a $32 copay for the outpatient office visit. This outpatient office visit falls within 
the specialty physician office 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 reduce the copayment for the 
outpatient office visit with an ophthalmologist (99214) provided on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for routine eye wear. 
 
You asked the Plan to pay an additional amount for routine eye wear. You say that you want the Plan to pay an 
additional amount for these items. The Plan denied your request. The Plan says the benefits were applied 
correctly. The benefit maximum allowance had already been met. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to a $200 allowance per year. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of routine eye wear have not been met. Specifically, the record shows that you had exhausted your 
eyewear benefit maximum of $200 and are therefore, responsible for paying the remainder. Therefore, we 
decided that the Plan does not have to pay an additional amount for routine eye wear.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care and advance care planning provided 
on September 22, 2021, September 23, and September 25, 2021. 
 
You asked the Plan to pay for hospital care and advance care planning. You say that you would like this claim 
reprocessed for payment. The Plan denied your request. The Plan says original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent hospital care and advance care planning provided 
on September 22, 2021, September 23, and September 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for myocardial perfusion imaging, stress test, 
Rubidium, and Regadenoson injection provided on February 7, 2022. 
 
You asked the Plan to waive the cost share for myocardial perfusion imaging, stress test, Rubidium, and 
Regadenoson injection. You say that you should not be responsible for this cost share. The Plan denied your 
request. The Plan says the cost share has been applied correctly. 
 
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 enrollees must pay a 
20% coinsurance for in-network outpatient radiological diagnostic services, a $15 copayment for in network 
Medicare-covered non-radiological diagnostic services, a 20% coinsurance for each Medicare-covered medical 
supply obtained through an in-network provider, and a 20% coinsurance for each Medicare-covered Part B 
drug and non-chemotherapy drugs to treat cancer.  
 You have been asked to pay $623.13 for myocardial perfusion imaging, stress test, Rubidium, and 
Regadenoson injection. The myocardial perfusion imaging, stress test, and Rubidium fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. A Regadenoson injection falls within 
the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share 
for myocardial perfusion imaging, stress test, Rubidium, and Regadenoson injection provided on February 7, 
2022.  
 
 
Code Date of Service Billed Amount Allowed Amount Plan Paid Member 
Responsibility 
78431 2/7/2022 $3200.00 $1901.87 $1521.50 $380.37 
93015 2/7/2022 $ 140.00 $    62.90 $   47.90 $  15.00 
J2785 2/7/2022 $ 452.00 $ 238.80 $ 191.04 $  47.76 
A9555 2/7/2022 $ 900.00 $ 900.00 $ 720.00 $180.00 
Total     $623.13
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the molecular pathology procedure (Guardant Reveal) provided on 
February 16, 2022. 
 
You asked the Plan to pay for the Guardant Reveal. You say that you would like this claim to be processed in-
network. The Plan denied your request. The Plan says that testing performed (Guardant Reveal) for minimal 
disease testing does not meet all of the required criteria for limited coverage. 
 The Plan follows Medicare rules. Medicare rules say that limited coverage is provided for minimal residual 
disease (MRD) testing in cancer when all the criteria listed in the Medicare rules section of this letter 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 pay for the Guardant Reveal. Our reviewer says that 
the molecular pathology procedure (Guardant Reveal) meets the criteria for coverage. Our physician reviewer 
found the documentation indicates that the enrollee has a history of malignant neoplasm of the cecum. Our 
reviewer also found that the enrollee meets all of the criteria for MRD testing in cancer. 
 
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 Guardant Reveal have been met. Therefore, we decided that the Plan has to 
pay for the molecular pathology procedure (Guardant Reveal) provided on February 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network, and it was determined these services 
were 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 an office visit provided on January 5, 2022, by an 
out-of-network (OON) provider.