Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional accessories for a prosthetic (L5620, L5634, 
L5637, L5785, L5976, L5629). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested items exceed the enrollee's medical needs and cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided records do not document the patient has had a Syme's amputation or below 
the knee amputation to meet criteria for the requested accessories. The documents report the patient has had a 
transmetatarsal amputation for which these requested accessories are not appropriate 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional accessories for a prosthetic (L5620, L5634, L5637, L5785, L5976, L5629).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospitalization provided from August 5, 2021, 
to August 12, 2021. 
 
You asked the Plan to pay for the inpatient hospitalization. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says medical necessity could not be determined for the 
services provided on these dates of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient hospitalization provided 
from August 5, 2021, to August 12, 2021. have been met. Specifically, medical records were not provided with 
this case. The record shows that the Plan made multiple attempts to obtain medical records, but they were not 
provided. Without this information, we cannot determine if the services provided were medically necessary. 
Therefore, we decided that the Plan does not have to pay for the inpatient hospitalization provided from August 
5, 2021, to August 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on May 2, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that the referring provider sent the specimens to 
your laboratory to process, and you would like the claim to be paid. 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 pathology services provided on May 2, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that the requested wheelchair ramp is medically 
necessary due to the enrollee's chronic obstructive pulmonary disease. The Plan denied your request. The Plan 
says Wheelchair ramps are not covered by Medicare as they are considered comfort or convenience or hygienic 
equipment and not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
February 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that medically necessary services were 
rendered to the enrollee. The Plan denied your request. The Plan says prior authorization was not obtained 
before the service was provided. The Plan also says that the service was not urgent or emergent in nature. 
 
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 subsequent nursing facility care (99309) 
provided on February 7, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unlisted molecular pathology procedure (81479). 
 
You asked the Plan to pay for genetic testing. You say that you disagree with the denial of this claim and are 
requesting reconsideration. The Plan denied your request. The Plan says the claim did not include the required 
DEX Z-CodeTM required for billing this type of test. The provider, supplier, or beneficiary, as appropriate, must 
furnish to the intermediary or carrier sufficient information to determine whether payment is due and the 
amount of payment. 
 
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 81479 is not supported in the medical record. Specifically, the claim did not include the 
required DEX Z-Code required for billing this type of test. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for an unlisted molecular pathology procedure (81479).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient clinic visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient clinic visit. You say that the enrollee was advised that they 
must seek care with the network orthopedic providers. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
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. We found no exception that would 
require the Plan to pre-approve the outpatient clinic visit. The records provided for review do not show that the 
outpatient clinic visit was urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve 
the outpatient clinic visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on May 8, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that the enrollee was unaware that they needed 
to get care from an in-network provider. The Plan denied your request. The Plan says the rendering provider is 
an OON provider and there was no referral from an in-network provider or an 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 pathology services provided on May 8, 2022, 
by an out-of-network (OON) provider.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the copayment for emergency room services on December 19, 2021. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says that the cost sharing you are being charged 
is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not send the correct Evidence of Coverage (EOC) that corresponds 
to the date of service. Therefore, we decided that the Plan has to waive the copayment for emergency room 
services on December 19, 2021.  
 
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 copayment for lab work provided on March 10, 2022. 
 
You asked the Plan to waive the copayment for lab work. You say that you had this lab work done during your 
annual visit and should not have to pay a separate copayment. The Plan denied your request. The Plan says the 
copayment that was applied was 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 a $10 
copayment for other Medicare-covered laboratory tests that are not FIT tests.  
 
You have been asked to pay a $10 copayment for lab work. Lab work 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 lab work provided on March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on May 12, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that the referring provider sent the specimens to 
your laboratory to process, and you would like the claim paid. 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 pathology services provided on May 12, 2022, 
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you didn't have a choice 
to take an ambulance or not. Due to this fact, you feel you should not have to pay this copayment. The Plan 
denied your request. The Plan says you were charged this cost sharing 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 $300 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $300 for these 
services. 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 services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy on May 24, 2022. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you want to appeal the amount be 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $225 
copayment for each Medicare-covered outpatient hospital facility visit. We cover medically-necessary services 
you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered 
services include but are not limited to the following and cost sharing may apply, services in an emergency 
department or outpatient clinic, such as observation services or outpatient surgery. 
 
 
 
 
 You have been asked to pay a $225 copayment for colonoscopy. Colonoscopy falls 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 waive the copayment for colonoscopy on May 
24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, routine venipuncture, laboratory testing, 
anesthesia services, and a laparoscopy provided from February 16, 2022, to March 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit, routine venipuncture, laboratory testing, anesthesia services, and a 
laparoscopy. You say that two of the Plan representatives tell you that the claims should not be denied as the 
provider is in-network and nothing has changed in the Plan from 2021 to 2022. The Plan denied your request. 
The Plan says services from non-participating providers are not covered unless preauthorized. 
 
 
 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, routine venipuncture, laboratory 
testing, anesthesia services, and a laparoscopy provided from February 16, 2022, to March 23, 2022, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed with a date of service of February 
17, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that as a general rule, the date of service (DOS) of a 
laboratory test/service must be the date the specimen was collected. If the specimen was stored for more than 
30 calendar days before testing, the specimen is considered to have been archived and the DOS of the 
test/service must be the date the specimen was obtained from storage. 
 
We looked at the file and Medicare rules. The records show that the specimens were collected on May 6, 2021, 
and February 8, 2022, and received on February 7, 2022, and February 9, 2022. Based on this information, we 
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that 
the Plan does not have to pay for laboratory services billed with a date of service of February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT testing provided to the enrollee on January 
28, 2022. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this testing is not FDA-approved.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that molecular profiling is not considered a standard of care in the treatment of head and neck 
cancers and is not supported by the National Comprehensive Care Network (NCCN) Guidelines or the medical 
literature. Other treatments exist such as Epstein-Barr virus (EBV) testing and targeting if positive and the use 
of Cetuximab, Afatnib, or other chemotherapies. The service is not reasonable or 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Tempus xT testing provided to the enrollee on January 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays on January 21, 2022. 
 
You asked the Plan to waive the copayment for x-rays. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $20 
copayment per day, per provider, for Medicare-covered x-ray services. Covered services include but are not 
limited to X-rays. 
 
You have been asked to pay a $20 copayment for x-rays. X-rays fall 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 x-
rays on January 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the hospital called the 
transport for you, therefore they should be responsible for the copayment. The Plan denied your request. The 
Plan says you were charged this cost sharing 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 $440 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $440 for these 
services. 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 services.