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

 
We decided that the Plan does not have to pay for laboratory services provided on January 14, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 January 14, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on January 21, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization 
is required prior to an out-of-network visit. 
 
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 services 
provided on January 21, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing rendered on December 31, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that FANCC genetic testing is non-covered. 
 
We looked at the file and Medicare rules. The testing at issue is FANCC genetic testing. Therefore, we decided 
that the Plan does not have to pay for the FANCC genetic testing rendered on December 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 4, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on February 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing coded 
with 81161, 81286, 81410, 81411, 81413, 81414 and 81479 provided October 18, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you believe that the treatment sought is 
medically necessary to treat the enrollee based on the enrollee's condition. The Plan denied your request. The 
Plan says these services do not meet coverage requirements and not covered by Medicare. 
 
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, we find that CPT code 81161, 81286, 81410, 81411, 81413, 81414 and 81479 is not supported in the medical record. Specifically, genetic cardiovascular screening testing does not meet the definition of 
cardiovascular disease screening as outlined by 42 CFR 410.17 and is excluded from Medicare coverage. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the cardiac risk assessment genetic 
screening testing coded with 81161, 81286, 81410, 81411, 81413, 81414 and 81479 provided October 18, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 vaccine provided on March 31, 2021, and 
April 30, 2021. 
 
You asked the Plan to pay for the COVID-19 vaccine. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed must be submitted to Original Medicare. 
 
The Plan must follow Medicare rules. The rules state that for COVID-19 vaccines provided in calendar years 
2020 and 2021, claims must be submitted to Original Medicare. 
 
Review of the file shows that the service at issue is COVID-19 vaccines. This vaccine was provided in the 
calendar year 2021. This means that the claims for these services must be submitted to Original Medicare for 
payment. Therefore, we decided that the Plan does not have to pay for the COVID-19 vaccine provided on 
March 31, 2021, and April 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment on December 20, 2021, 
to March 20, 2022. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says the cost share applied 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 20% 
coinsurance for oxygen equipment. The total allowed amount of the oxygen equipment is $151.70, resulting in 
a coinsurance amount of $30.34. 
 
You have been asked to pay 20% coinsurance for oxygen equipment. Oxygen equipment falls within the 
oxygen 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 oxygen equipment 
on December 20, 2021, to March 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services you need can be provided safely in other settings. 
 
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. 
Subdural hematoma is an IRF compliant diagnosis, and you have multiple comorbidities that would benefit 
from close medical supervision. Evaluating therapies recommend less intense therapy due your poor endurance and inability to tolerate intense therapy. Our physician reviewer found that your condition does not meet 
Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary cardiac condition assessment testing provided on 
January 15, 2022. 
 
You asked the Plan to pay for genetic testing. You say that this was denied as experimental in error. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because this testing is 
screening in nature which is not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover 
this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiac 
condition assessment testing provided on January 15, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from July 21, 2021, to 
January 5, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says this provider type is 
not part of the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from  
July 21, 2021, to January 5, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic testing services on January 17, 
2022. 
 
You asked the Plan to waive the copayment for diagnostic testing services. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says the cost share applied 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 50% 
coinsurance for diagnostic testing services. The total allowed amount of the diagnostic testing services is 
$434.10, resulting in a coinsurance amount of $217.03. 
 
You have been asked to pay 50% coinsurance for diagnostic testing services. Diagnostic testing 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 diagnostic testing services on January 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member's nursing, medical management and rehabilitation needs do 
not require an interdisciplinary team approach to delivery of rehabilitation care. 
 
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.  
 Clinical documentation shows that this patient is status post single joint replacement and although there are 
documented hospital complications there is no documentation to show that further medical monitoring or 
management of diagnosis would be required on an inpatient basis. There is no clinical documentation to show 
that this case of single joint arthroplasty would require intense or interdisciplinary rehabilitation. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Trio nerve stimulator device provided to the 
enrollee on December 9, 2021. 
 
You asked the Plan to pay for the device. You say that this is not experimental. The Plan denied your request. 
The Plan says the denial of this stimulator device is appropriate given the clinical scenario. 
 
The Plan must follow Medicare rules. Medicare rules say that where electric nerve stimulation is employed to 
treat motor function disorders, no reimbursement may be made for the stimulator or for the services related to 
its implantation since this treatment cannot be considered reasonable and necessary. 
 
The provider's website itself acknowledges that this device is new therapy and not covered by Medicare. Based 
on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, 
we decided that the Plan does not have to pay for the Cala Trio nerve stimulator device provided to the enrollee 
on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses, photochromatic tint and anti-reflective 
coating provided on January 20, 2022. 
 
You asked the Plan to pay for progressive lenses, photochromatic tint and anti-reflective coating. The Plan 
denied your request. The Plan says the Plan will cover 20% of the Medicare allowable rate for standard 
eyeglasses (standard frames, standard lenses) or contacts after surgery. 
 
The Plan contract says covered eyeglasses after cataract surgery includes standard frames and lenses as defined 
by Medicare. We looked at the file, the Medicare rules and the Plan's rules. The file shows that Medicare and the Plan cover 
standard eyeglasses. Therefore, we decided that the Plan does not have to pay for progressive lenses, 
photochromatic tint and anti-reflective coating provided on January 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on 
January 12, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you feel the enrollee 
should not owe the copayment. The Plan denied your request. The Plan says you have been charged the correct 
copayment 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 $295 
copayment per a one-way trip both in and out-of-network.  
 
 
 You have been asked to pay a $295 copayment for the ambulance transport. The ambulance transport 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 
the ambulance transport provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for pacemaker evaluation services (93283) 
provided on February 9, 2022. 
 
You asked the Plan to waive the copayment for the pacemaker evaluation services. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on 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 $45 
copayment for Prosthetic devices and related supplies.  
 
You have been asked to pay a $45 copayment for the pacemaker evaluation services. Pacemaker evaluation 
services fall within the Prosthetic devices and related 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 pacemaker evaluation services (93283) provided on February 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to be able to tolerate fifteen hours per week of rehabilitative services and regular physician 
evaluation. Your care needs can be met at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found following the procedure, the enrollee was found to have peritonitis from perforated 
bowel. The record indicates that the enrollee has had a complicated hospital course and is still febrile from an 
unknown source. The record indicates that the enrollee still requires acute care services. The enrollee continues 
to receive acute care services, and these have not been denied. The medical record does not indicate that the 
enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for an ultrasound provided by on March 1, 
2022. 
 
You asked the Plan to lower the copayment for the ultrasound. You say that your copayment should be less, 
and it was a simple procedure. The Plan denied your request. The Plan says the proper copayment was applied 
for the service that was rendered. 
 
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 $110 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
  You have been asked to pay a $110 copayment for the ultrasound. the 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 lower 
the copayment for an ultrasound provided by on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing rendered on October 31, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that FANCC genetic testing is non-covered. 
 
We looked at the file and Medicare rules. The testing at issue is FANCC genetic testing. Therefore, we decided 
that the Plan does not have to pay for the FANCC genetic testing rendered on October 31, 2021.