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

 
We decided that the Plan does not have to pay for the validity testing provided on May 10, 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 providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the validity testing provided on May 10, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing for cancer (code 81455) provided on June 27, 2022. 
 
You asked the Plan to pay for the testing. You say that the testing was medically necessary. The Plan denied 
your request. The Plan says that there are no doctor notes showing why the testing was ordered or how it will 
be used. Without complete medical notes, medically necessity cannot be determined. 
 
The Plan follows Medicare rules. Medicare rules say that the testing is reasonable and necessary when the 
patient has either recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer and has not 
been previously tested with a CGP for the same cancer genetic content and has decided to seek further cancer 
treatment. 
 
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 testing. Our reviewer says that the 
service is medically reasonable and necessary. Our physician reviewer found the enrollee has metastatic 
pancreas cancer and has not previously been tested with a CGP for the same genetic content. The enrollee has 
decided to seek further treatment. The test performed is able to detect genes that would identify approved 
subsequent therapies.  
 
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 testing have been met. Therefore, we decided that the Plan has to pay for the 
genetic testing for cancer (code 81455) provided on June 27, 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 an epidural steroid injection. 
 You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection 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 an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found that 
there is no documentation of conservative therapy. Therefore, the criteria of the LCD are not met and the 
request is deemed not medically reasonable or 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance service provided on February 
17, 2022. 
 
You asked the Plan to waive the copayment for an ambulance service. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 you must pay a $150 
copayment for ambulance services.  
 
You have been asked to pay a $150 copayment for an ambulance service. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance 
service provided on February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 21, 2022, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says the out-of-
network 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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on June 21, 2022, by 
an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and a fine needle aspiration biopsy provided 
on June 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and a fine needle aspiration biopsy. You say that this provider 
regularly complies with all administrative requirements for payments. The Plan denied your request. The Plan 
says this provider is not a network provider with the Plan. The Plan also says that these services were not 
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 an office visit and a fine needle aspiration biopsy 
provided on June 7, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pancreas procedure (48999) provided on June 6, 2022. 
 
You asked the Plan to pay for a pancreas procedure. You say that this should be fully paid for. The Plan denied 
your request. The Plan says this is not supported in the records. 
 
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 48999 is unlisted procedure, pancreas. 
 
We find that CPT code 48999 is not supported in the medical record. Specifically, the records do not document 
that a pancreas procedure was performed on this date of service. Based on this information, we decided that 
Medicare rules for coverage of a pancreas procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for a pancreas procedure (48999) provided on June 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator provided on July 14, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an oxygen concentrator. You say that the in-network provider did not have the 
item you needed, so you went with an out-of-network provider. You also say that there should be a partial 
reimbursement of at least 35% for out-of-network. The Plan denied your request. The Plan says the 
authorization on file was issued to a different provider. 
 
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 oxygen concentrator provided on July 14, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for pneumatic compression device provided 
on July 05, 2022. 
 
You asked the Plan to waive the coinsurance for pneumatic compression device. You say that you were told 
this would be covered in full. The Plan denied your request. The Plan says this cost sharing was charged 
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 you must pay 20% 
coinsurance for durable medical equipment. 
 
You have been asked to pay 20% coinsurance for pneumatic compression device. This item/service falls within 
the durable medical equipment 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 
pneumatic compression device provided on July 05, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided from December 16, 2021, to 
December 20, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
are included within the global surgery package. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that procedure code 42700 was billed for services provided on December 14, 2021. Procedure 
code 42700 has a 10-day global surgery period. The claim at issue was not billed with a modifier to indicate the 
services were separate and distinct from the procedure provided on December 14, 2021. Based on this 
information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the surgery services provided from December 16, 
2021, to December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene expression profiling of melanoma (0089U) provided 
on July 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for gene expression profiling of melanoma. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this service is not covered when provided OON without 
prior approval. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the gene expression profiling of melanoma 
(0089U) provided on July 25, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on April 28, 2022. 
 
You asked the Plan to pay for the services provided. You say that you were told the services would be paid. 
The Plan denied your request. The Plan says the claim processed 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 you must pay a 20% 
coinsurance for durable medical equipment.  
 
We looked at the file and the rules. The Plan has agreed to pay for the nasal interface used with your positive 
airway pressure device, minus the 20% coinsurance. This service falls within the durable medical equipment. 
benefit category. The $5 fee for shipping is not payable. 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 further pay for the 
durable medical equipment provided on April 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on May 23, 
2022, to July 13, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged 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 you must pay a $150 
copayment for Outpatient surgery. 
 
You have been asked to pay a $150 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery 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 outpatient surgery 
provided on May 23, 2022, to July 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the physical therapy (PT) evaluation and 
occupational therapy (OT) evaluation provided on July 20, 2022, and July 21, 2022. 
 
You asked the Plan to waive the copayments for the PT and OT evaluations. You say that you believe that you 
and the insurance company should not be charged as much for these visits. You also say that you do not think 
you received these services. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. The Plan also says they confirmed with the provider that these evaluations did take place. 
 
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 $40 
copay for Outpatient rehabilitation services.  
 
 
 
 You have been asked to pay $40 copays for the PT and OT evaluations. These services fall within the 
Outpatient rehabilitation 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 copayments for 
the physical therapy (PT) evaluation and occupational therapy (OT) evaluation provided on July 20, 2022, and 
July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to waive the additional cost for the eye exam. We decided that the Plan does not 
have to pay for the eye refraction.  
 
You asked the Plan to fully pay for the eye exam and the eye refraction. You say that the provider was in-
network. The Plan says that the claim was processed correctly, and the benefit was exhausted. 
 
We decided that the Plan has to waive the remaining amount for the eye exam.  
 
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 pay $0 when you 
receive a routine eye exam from an in-network provider. The record shows the service was provided in-
network, which means the Plan is obligated to pay $75 and cannot charge you for this service.  
 
We also decided that the Plan does not have to pay for the eye refraction. 
 
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 up to $75 for a routine eye exam and refraction. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid the $75 allowance towards the eye exam. 
This means you are responsible for the full cost of the eye refraction. Based on this information, we decided 
that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan 
does not have to pay for the eye refraction. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 25, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 the laboratory services related to end-stage renal disease (ESRD) provided on April 
25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic services (97530) provided on September 10, 
2021. 
 You asked the Plan to pay for therapeutic services. You say that these services were medically necessary and 
were billed correctly. 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.  
 
We find that these services are not supported in the medical record. Specifically, the documentation shows that 
this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Certified 
Occupational Therapy Assistant. There is no indication that the Nurse Practitioner was present on site while the 
therapy services were being rendered. The incident-to requirements have not been met in this case. Based on 
this information, we decided that Medicare rules for coverage of therapeutic services have not been met. 
Therefore, we decided that the Plan does not have to pay for therapeutic services (97530) provided on 
September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the requested supplies are medically 
necessary due to type 2 diabetes mellitus with other specified complication, The Plan denied your request. The 
Plan says the enrollee does not meet coverage criteria for the requested CGM and supplies. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant at surgery services provided on May 26, 2022. 
 
You asked the Plan to pay for assistant at surgery services. You say that the services at issue were billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for assistant at surgery services provided 
on May 26, 2022.