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

 
We decided that the Plan does not have to waive the copayment for a gastroenterology audio visit provided on 
September 13, 2021. 
 
You asked the Plan to waive the copayment for a gastroenterology audio visit. You say that you were told you 
had to do an audio visit before getting a colonoscopy. You also say that you tried calling the office 4-5 times to 
get an appointment and never received a call back. 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 $30 
copayment for a specialist visit, including telehealth services.  
 
 You have been asked to pay a $30 copayment for a gastroenterology audio visit. A gastroenterology audio visit 
falls within the Physician/Practitioner Services, Including Doctors Office Visits 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 a gastroenterology audio visit provided on September 13, 2021.  
 
Your complaint about calling the office multiple times and not receiving a call back is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that your feet are extra wide and cannot find shoes in 
your size. You also have bunions and when you walk you feel a lot of pressure that hurts. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
September 21, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463) and a flu vaccine 
(90662, G0008, 90472) provided on September 20, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a hospital outpatient clinic visit and a flu vaccine. You say that you have 
submitted documents to support the medical necessity of the services provided for the member, in good faith. 
The Plan denied your request. The Plan says this provider is not a network provider with the Plan, and they 
have also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan 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 hospital outpatient clinic visit (G0463) and a flu 
vaccine (90662, G0008, 90472) provided on September 20, 2021, 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 July 8, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 genetic testing provided on July 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the male vacuum erection system coded as L7900 and 
L7902. 
 
You asked the Plan to pre-approve the male vacuum erection system. You say that the medical records 
provided will show proof of medical necessity.  The Plan denied your request. The Plan says this item is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the male vacuum erection system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the male vacuum erection system coded as L7900 and L7902.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
March 17, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 
17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for an abdominal ultrasound provided on 
August 20, 2021. 
 
You asked the Plan to waive the cost sharing for an abdominal ultrasound. You say that you do not normally 
pay for any tests. The Plan denied your request. The Plan says they decided to partially overturn their original 
decision and reduce your cost sharing and apply 20% coinsurance instead. 
 
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 20% 
coinsurance for diagnostic radiology, including ultrasounds. 
 
  
You have been asked to pay $18.95, which is 20% of the allowed amount for an abdominal ultrasound ($94.76 
allowed amount x 20% coinsurance = $18.95). An abdominal ultrasound 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 cost sharing 
for an abdominal ultrasound provided on August 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 2, 2021, to June 
28, 2021. 
 
You asked the Plan to pay for the home health services. You say that you would like this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says the initial Request for Anticipated 
Payments (RAP) claim was not received within 5 calendar days from the start of care. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, June 2, 2021. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from June 2, 2021, to June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus panel provided on June 9, 2021 and billed with 
CPT codes 81206, 81235, 81292, 81301, 81321. 
 
You asked the Plan to pay for the Tempus panel. You say that you would like reconsideration because this 
testing is medically necessary. The Plan denied your request. The Plan says these services were not billed 
correctly. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Tempus panel have not been met. Specifically, it is not appropriate to bill individual CPT codes 
for a single panel. Therefore, we decided that the Plan does not have to pay for the Tempus panel provided on 
June 9, 2021 and billed with CPT codes 81206, 81235, 81292, 81301, 81321.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 81479) provided on July 
28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code 81479 (1 
Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of 
the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an On Campus- Outpatient Hospital setting POS 22. Also, the laboratory 
results submitted indicate the specimen was collected on July 16, 2021, and received by the lab on July 17, 
2021; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional 
information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (CPT code 81479) provided on July 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital care and brain surgery (CPT code(s): 
61510RT, 61781RT, and 69990RT) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you have a brain tumor and have 
been waiting five (5) months to get it removed. The Plan denied your request. The Plan says this is not a 
network provider. 
 
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 the out-of-network services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this case that you are noted to have a brain tumor (likely a schwanoma). 
The performance of a craniotomy for resection would be a clinically appropriate procedure. However, the 
request in this case for the provision of care on an out-of-network basis would not otherwise meet the Medicare 
definition of medical necessity at this time. While you appear to have some symptoms from the tumor, there is 
not an emergent need for intervention at this time (in contrast to other types/forms of brain tumors/masses). 
The choice to go out-of-network at this time otherwise appears to have been for your convenience (elective) in 
nature. There is no evidence of a network insufficiency to provide care in a timely manner. This service out-of-
network would not be medically necessary. 
 
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 out-of-network services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital care and brain surgery (CPT code(s): 61510RT, 61781RT, 
and 69990RT) to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that your foot orthotics are deteriorating and need to 
be replaced. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane for the enrollee. 
 
You asked the Plan to pre-approve Abraxane. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that there is no indication their preferred drugs would likely be less 
effective, and/or cause adverse effects for the member. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Abraxane. Our reviewer says that 
Abraxane is not medically reasonable and necessary. The patient has not tried and failed Taxol (paclitaxel) or 
Taxotere (docetaxel). There is no indication that pacltiaxel or docetaxel would be less effective for the enrollee. 
Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Abraxane. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Abraxane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Abraxane for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
November 20, 2019, to November 25, 2019. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the Payment Integrity post-service post-pay clinical validation audit shows that the provider has 
reported inpatient hospital services with the incorrect DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 698 (OTHER KIDNEY AND URINARY 
TRACT DIAGNOSES WITH MCC). 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 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found the appeal letter mentions that the enrollee clearly met Sepsis 2 guidelines with 
SIRS criteria. While these values are noted, the enrollee quickly improved with treatment in the emergency 
department. SIRS criteria are expected as an appropriate response to infection; however, the documentation 
does not support a manifestation of systemic infection beyond that evidenced by SIRS criteria. While the 
enrollee's symptoms warranted consideration of sepsis as a possible diagnosis, there was no evidence of life-
threatening organ dysfunction due to a dysregulated host response to the infection. The review has determined 
that it was appropriate to remove the diagnosis of A41.9. The more appropriate DRG in this case is DRG 699 
(OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from November 20, 2019, to November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) and the urinalysis 
(81003) provided on November 9, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $35 
copayment per visit for a specialist office visit.  
 
You have been asked to pay a $35 copayment for the specialist office visit provided. 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 the office visit (99213) and the urinalysis 
(81003) provided on November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine (CPT code 90736) provided on May 7, 
2021. 
 
You asked the Plan to pay for the shingles vaccine. You say that you were misinformed as the representative 
you spoke with should have provided the right information that the shingles vaccine needs to be administered 
by a pharmacist. The Plan denied your request. The Plan says this is a Part D injectable and not payable under 
your Part B benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (CPT code 90736) 
provided on May 7, 2021.  
 Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the upper denture. You say that you haven't used this service before; you 
were going to have this denture provided by someone else, but then decided you were not comfortable with 
their care. The Plan denied your request. The Plan says the Plan previously paid for a complete upper denture 
which was provided for you on December 3, 2020. This service may only be covered once every 60 months. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan can cover one 
complete upper denture (D5110, D5130, D5211, D5213, D5225) per 60 months. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the denture is requested in a frequency 
that is not covered under this benefit. The record includes a copy of a claim showing that you received a 
complete upper denture on December 3, 2020, and this service was covered by the Plan at that time. Therefore, 
we decided that the Plan does not have to pre-approve a complete upper denture (D5110).