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

 
We decided that the Plan does not have to pay for the laboratory services provided on January 26, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you sent additional documentation to 
support the claim. The Plan denied your request. The Plan says the rendering and referring providers are both 
OON providers and there was no approved authorization. Also, the service rendered was 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 the laboratory services provided on January 26, 
2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound urine capacity measure (51798) provided on 
September 29, 2021. 
 
You asked the Plan to pay for the urine capacity measure. You say that this service is supported in the record 
and was billed appropriately. The Plan denied your request. The Plan says this service is not supported as 
billed. 
 
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 51798 is measurement of post-void residual urine and/or 
bladder capacity by ultrasound, non-imaging. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the urine capacity measure. Our reviewer says that the 
criteria for billing code 51798 are not met in this case. Our reviewer found the procedure report does not 
include documentation to support measurement of post-void urine and/or bladder capacity. Our coder says they 
were unable to cite the report as this procedure was not found in the documentation provided. Therefore, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the urine capacity measure have not been met. Therefore, we decided that the 
Plan does not have to pay for the ultrasound urine capacity measure (51798) provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit provided on 
January 12, 2022. 
 
You asked the Plan to reduce the copayment for the office visit. You say that your copayment should be $35 
for in-network specialty doctors. 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 $40 
copayment for services obtained from a specialist.  
 
You have been asked to pay a $40 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's 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 reduce the copayment for a specialist office visit provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on September 27, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that you did not have a say in who treated 
you. The Plan denied your request. The Plan says you, or your primary care physician (PCP), must obtain 
authorization from the Plan prior to seeking to care. 
 
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 domiciliary or rest home visit provided on 
September 27, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the spirometry test performed on January 
27, 2022. 
 
You asked the Plan to waive the copayment for the spirometry test. You say that you've never been charged 
before for the same test. The Plan denied your request. The Plan says the copayment was 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 you must pay a $100 
copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service.  
 
You have been asked to pay the allowed amount of $30.63 rather than the standard $100 copayment for the 
spirometry test. The spirometry test 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 copayment for the spirometry test performed on January 27, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for MRI provided on March 24, 2021. 
 
You asked the Plan to waive the copayment for MRI. You say that your doctor told you the MRI was covered 
in full, so you should not have to pay this bill. The Plan denied your request. The Plan says coinsurance is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $150 
copayment for all other diagnostic and nuclear medicine radiological services.  
 
  You have been asked to pay $150 copayment for the MRI. The MRI 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 copayment 
for MRI provided on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 2, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you should not have to pay since 
the bill is two years old. 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 $35 
copayment for each specialist office visit.  
 
 
 You have been asked to pay a $35 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's 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 specialist office visit provided on December 2, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care stay provided on November 29, 2021 to 
December 4, 2021 at an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient hospital care stay. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that the services were not approved in advance. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for the inpatient 
hospital care stay provided on November 29, 2021 to December 4, 2021 at an out-of-network (OON) provider.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drainable ostomy pouch (A5063) provided on June 9, 2021. 
 
You asked the Plan to pay for a drainable ostomy pouch. You say that the claim was billed correctly based on 
Medicare guidelines. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code A5063 has a status indicator of P on the Physician Fee Schedule. This means that CPT code A5063 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of a drainable ostomy pouch have not been met. Therefore, we decided that the Plan does not have to pay for a 
drainable ostomy pouch (A5063) provided on June 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the diagnostic service provided on January 11, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic service. You say that there was no programming 
involved, it was just an adjustment and something your doctor has never charged you for before. The Plan 
denied your request. The Plan says that the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.  
 
We looked at all the case file information and determined that the code itself is for physician services not any 
component of a diagnostic service. Since the code billed is for physician services, this should be included in the 
copayment for the specialist visit. Therefore, we decided that the Plan has to waive the copayment for the 
diagnostic service provided on January 11, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a cologuard test provided on February 17, 
2022. 
 
You asked the Plan to waive the deductible for the cologuard test. You say that the claim processing was 
incorrect and is blocking your access to a preventative service. You say that you believe your plan requires 
them to pay the claim in full. The Plan denied your request. The Plan says the deductible 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 a $5,400 deductible which applies to the cologuard test.  
 
The item or service you asked the Plan to waive the deductible for falls within the Colorectal cancer 
screening benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a deductible which applies to the cologuard test. This cost sharing is a contractual obligation that had 
not been met at the time the cologuard test was received on February 17, 2022. Therefore, we decided that the 
Plan does not have to waive the deductible for a cologuard test provided on February 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio infusions from an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
Leqvio infusions from an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical excision of nasal tissue and re-shaping. 
 
You asked the Plan to pre-approve the nose surgery. You say that this is medically necessary treatment. The 
Plan denied your request. The Plan says this is not medically necessary reconstructive surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 nose surgery. Our reviewer says that 
the requested procedure is not considered medically reasonable and necessary. Our reviewer found the record 
indicates that the enrollee has a history of rosacea, rhinophyma, and basal cell carcinoma. The requested 
service is to treat rhinophyma. The record does not document the presence of any complications form the 
rhinophyma that would indicate the need for intervention. The requested procedure appears to be cosmetic in 
nature. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  
 
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 nose surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve surgical excision of nasal tissue and re-shaping.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says a setting that could 
be delivered by BiPAP is not covered 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our physician reviewer 
found that you were admitted to the hospital with worsening respiratory symptoms and mental status changes 
related to excess sedating medication use, with hypercarbic respiratory failure. There is a diagnosis of COPD, 
but there are no pulmonary function tests to assess severity. There is no arterial blood gas done while stable as 
an outpatient to confirm chronic carbon dioxide retention. If that were confirmed, the enrollee may benefit 
from BiPAP during sleep, with or without AVAPS. However, that has not been tried as an outpatient, and 
Medicare does not cover a home ventilator when used as BiPAP. Therefore, a home ventilator 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on October 
27, 2021. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you did not receive 
appropriate care, so you should not have to pay this bill. The Plan denied your request. The Plan says 
coinsurance is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $40 
copayment for lab services when provided in an outpatient hospital facility.  
 
You have been asked to pay $40 copayment for laboratory services. Laboratory services 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 copayment for laboratory services provided on October 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay from June 7, 2021, 
through June 28, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you were readmitted three 
weeks later for the same illness so you feel this should be counted as one admission. The Plan denied your 
request. The Plan says coinsurance is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $395 
copayment for each in-network, Medicare-covered days 1-5 and a $0 copayment for each additional day 6-90.  
 
  You have been asked to pay $1,975 for inpatient hospital stay ($395/day x 5 days = $1,975). The inpatient 
hospital stay falls within the Inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital stay from June 7, 2021, through June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on December 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that the claim should be processed using in-network 
benefits. The Plan denied your request. The Plan says these tests are considered not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for myeloproliferative disease is only 
covered under certain medical indications.  
 
We looked at the file and Medicare rules. The records provided do not indicate that the enrollee has a 
myeloproliferative disease, refractory or metastatic cancer. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab testing services provided on December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 21, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT 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 September 21, 2021.