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

 
We decided that the Plan does not have to pay for debridement provided on July 7, 2022, by an OON provider. 
 
You asked the Plan to pay for debridement. You say that the services performed were provided on an urgent 
basis per request received from the skilled nursing facility's primary care physician. 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 debridement provided on July 7, 2022, by an OON 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician/practitioner service provided on 
January 7, 2022. 
 
You asked the Plan to waive the copayment for physician/practitioner service. You say that you were unaware 
the provider was out of network, and no one notified you of that. 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 $40 
copayment for Medicare-covered primary care doctor visit.  
 
You have been asked to pay $40 copayment for physician/practitioner service. This item/service falls within 
the Medicare-covered primary care doctor visit 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 physician/practitioner service provided on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits on October 8, 2021, 
and January 14, 2022. 
 
You asked the Plan to waive the copayments for specialist office visits. You say that you should not be 
responsible to pay this. 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 $45 
copayment for in-person specialist visit.  
 
You have been asked to pay $36 for the specialist office visit on October 8, 2021, which is less than the 
standard copayment. You have also been asked to pay $40 for the specialist office visit on January 14, 2022, 
which is less than the standard copayment. The total you owe is $76 ($36 + $40 + $76). This item/service falls 
within the in-person specialist visit 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 
specialist office visits on October 8, 2021, and January 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 74176 and 71045 provided on April 28, 
2022. 
 
You asked the Plan to pay for procedure codes 74176 and 71045. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in 
hospice from March 24, 2022, to April 8, 2022. The Plan says, per Medicare guidelines, the provider must bill 
Original Medicare for the services provided on April 28, 2022. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 8, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for procedure codes 74176 and 
71045 provided on April 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 18, 2021, billed with 
codes 81210, 81206, 81275, 81235, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194 and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that this claim should be reprocessed and paid. 
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on October 18, 2021, billed with codes 81210, 81206, 81275, 81235, 81276, 81292, 81295, 81298, 81301, 81317, 
81401, 81194 and 81309.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bifocal lenses and frames provided on December 27, 2021. 
 You asked the Plan to pay for bifocal lenses and frames. You say that when you got your glasses, the provider 
did not say anything about money you would owe after your vision allowance was applied. The Plan denied 
your request. The Plan says the claim was processed and paid on June 22, 2022. The Plan also says that a 
balance in the amount of $310.95 was assessed to the member correctly according to the member's 2021 EOC. 
 
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 says there is a $500 allowance for supplemental eyewear every year. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $500 allowance for supplemental 
eyewear every year. The Plan rules also say that you are responsible for all costs over and above the allowance 
amount. Based on this information, we decided that the Plan's rules for coverage of bifocal lenses and frames 
have not been met. Therefore, we decided that the Plan does not have to pay for bifocal lenses and frames 
provided on December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses (V2520) received on June 23, 2022. 
 
You asked the Plan to pay for contact lenses. You say that you thought the items would be covered. The Plan 
denied your request. The Plan says the items are a covered benefit, but you have exceeded the frequency limit. 
 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 once every two years. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of contact lenses have not been met. Specifically, the record shows your benefit for the requested item 
or service was exhausted on date of service January 21, 2021. Therefore, we decided that the Plan does not 
have to pay for contact lenses (V2520) received on June 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 11, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
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 code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist office visit and x-ray provided 
on June 22, 2022. 
 
You asked the Plan to waive the deductible for a specialist office visit and x-ray. You say that you should not 
be responsible to pay this. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to a specialist office visit and x-rays.  
 
The specialist office visit you asked the Plan to waive the deductible for falls within the in-person specialist 
visits benefit category. X-rays fall within the basic imaging service benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to a specialist 
office visit and x-rays. This cost sharing is a contractual obligation that had not been met at the time the office 
visit and x-ray were received on June 22, 2022. 
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to waive the deductible for a specialist office visit and x-ray 
provided on June 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided May 14, 2022, 
through May 24, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were not medically necessary.  
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided May 14, 2022, through May 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs physical therapy to be able to go 
home safely. The Plan denied your request. The Plan says the Medicare guidelines for admission to a SNF were 
not met and the enrollee's medical needs can be met in a long-term care facility. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there are no identifiable skilled nursing service needs. There are identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. 
This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 27, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary, and you are appealing 
with supporting records. The Plan denied your request. The Plan says the enrollee must receive care from a 
network 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 office visit provided on May 27, 2022 by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires additional therapies. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for SNF services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the medical records do not document the need for daily inpatient skilled nursing 
services. The provided records do not document a significant decline in the patients functional status to 
necessitate daily inpatient skilled therapy services. The enrollees care needs can be provided at a lower level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for surgical pathology and outpatient hospital 
services provided on May 4, 2022. 
 
You asked the Plan to reduce the copayments for surgical pathology and outpatient hospital services. You say 
that you should only be responsible to pay the copayments for a specialist visit. 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 $5 copayment for diagnostic tests and procedures at an in-network outpatient hospital facility. Your contract with 
the Plan also clearly says that you must pay a $225 copayment for in-network outpatient hospital services. The 
pathology testing was performed by a physician pathologist, which results in a separate copayment from the 
outpatient hospital services. 
 
You have been asked to pay $5 for the surgical pathology. You have also been asked to pay $175.39 for the 
outpatient hospital services, which is less than the standard $225 copayment. The total you owe is $180.39. 
Surgical pathology falls within the diagnostic tests and procedures benefit category. Outpatient hospital 
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 reduce the 
copayments for surgical pathology and outpatient hospital services provided on May 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair van transportation (A0130) provided on May 
26, 2022. 
 
You asked the Plan to pay for the wheelchair van transportation. You say that you needed assistance with the 
transportation due to your medical condition. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the wheelchair van transportation (A0130) provided on May 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot walk and are completely immobile. The 
Plan denied your request. The Plan says the criteria for admission to the IRF setting have not been met. 
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve the requested service. You say that you need to remain supine after surgery. 
The Plan denied your request. The Plan says you do not require frequent changes in body position. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed is only covered under 
certain medical indications.  
 
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 requested service. Our physician 
reviewer found that you have a medical history including morbid obesity, chronic lung disease and chronic 
back and neck pain. 
 In this case, the documentation does not support that you have a condition that requires frequent positioning of 
the bed and mattress to alleviate pain, promote good body alignment, prevent contractures or avoid respiratory 
infections in a way that an ordinary bed is not able to. Therefore, the request is not 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 requested service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a semi-electric hospital bed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 20, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
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 code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 20, 2022.