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

 
We decided that the Plan has to pay for laboratory testing (81455) billed for date of service May 16, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this testing was medically necessary and is 
supported in the medical records. The Plan denied your request. The Plan says that the date of service for a 
clinical laboratory test or the technical component of physician pathology service must be the date the 
specimen was collected. This claim was billed with a date of service of May 16, 2022, rather than the date the 
specimen was collected of May 4, 2022. 
 
The Plan must follow Medicare rules. The rules say that generally, laboratory services should be billed with the 
date of specimen collection as the date of service. However, there are three exceptions to this rule. The rules 
also 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. Specifically, the Plan has not acknowledged the exceptions to the applied rule 
and has provided no clear argument or evidence to support that none of the possible exceptions apply in this 
case. The specimen in this case was a piece of live tumor tissue which was collected as part of a hospital biopsy 
procedure. Based on the information provided, it is possible an exception has been met in this case. Therefore, 
we decided that the Plan has to pay for laboratory testing (81455) billed for date of service May 16, 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 pay for the lab services provided on March 25, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says records were not 
provided by the ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The documentation submitted does not contain medical records 
showing the ordering physicians intent that the testing be performed. 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 services provided on March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the second opinion outpatient office visits coded as 
99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214 and 99215 to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the office visits. You say that please consider overturning the denial of 
coverage for the enrollee's referral to the clinic for second opinion. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 the second opinion outpatient office visits coded as 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 
99214 and 99215 to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) and accessory 
provided on January 3, 2022. 
 
You asked the Plan to pay for the PCD and accessory. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary. If the base PCD is not covered, related accessories are not eligible for 
reimbursement.  
 
We looked at the file and Medicare rules. Per L33829, the PCD billed with code E0675 is not payable. As the 
PCD is not payable, the related accessory (E0673) is also not payable. Based on this information, we decided 
that Medicare rules for coverage of the PCD and accessory have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (PCD) and accessory provided on January 3, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
with the incorrect date of service. 
 
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 payment for CPT code 81455 is not supported in the medical record. Specifically, claim must be 
billed with the date the specimen was collected. The records show that the specimen was collected on March 
24, 2022. As such, the claim was billed with the incorrect date of service. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on April 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for esophagogastroduodenoscopy services provided on March 
11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for esophagogastroduodenoscopy services. You say that would like the Plan to 
reconsider pay for a Medicare-covered service. The Plan denied your request. The Plan says prior authorization 
was not obtained by the provider or facility. 
 
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 esophagogastroduodenoscopy services provided 
on March 11, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary for the enrollee 
to receive the LTACH services. The Plan denied your request. The Plan says admission to the LTACH does not 
meet the Medicare guidelines. 
 
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 that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can be safely administered at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it 
would not be clinically advantageous at this time. Completion of treatment at the current facility is 
recommended. 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 the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate 2.5mg tablets. 
 
You asked the Plan to pre-approve Methotrexate. You say that Methotrexate is medically necessary. The Plan 
denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methotrexate 2.5mg tablets.  
 
Benefits for Methotrexate may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested services are experimental/investigational. 
 
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 proton beam therapy. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the generally accepted standard of care for prostate cancer is to only offer proton beam 
therapy on clinical trials and to not routinely offer it to patients. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on April 20, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you are not able to afford to pay the 
copayment for a CT scan and would like the Plan to waive the cost. 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 $325 
copayment for other Medicare-covered diagnostic radiology.  
 
You have been asked to pay $312.19, which is less than the standard $325 copayment for a CT scan. This 
item/service 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 a CT scan provided on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. 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 an office visit provided on May 6, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health on May 09, 2022. 
 
You asked the Plan to waive the copayment for outpatient mental health. You say that you were not aware of 
the $40 copayment and feel that this was a preventative visit and should not have a copayment. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each individual or group therapy visit for outpatient mental health. Covered services include, but 
are not limited to mental health care, including care in a partial-hospitalization program, if a doctor certifies 
that inpatient treatment would be required without it. 
 
 
 
 
 You have been asked to pay a $40 copayment for outpatient mental health. This item/service 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 outpatient 
mental health on May 09, 2022.
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 May 
18, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that You should not be 
responsible to pay this because you did not receive any service. 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 $15 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for a specialist office visit. This item/service falls within the 
Physician/Practitioner services, including doctors 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 May 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on May 10, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you want to appeal the amount 
being charged. 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 20% 
coinsurance per Medicare-covered Part B drug. These drugs are covered under Part B of Original Medicare. 
Members of our plan receive coverage for these drugs through our plan. Covered drugs include drugs that 
usually arent self-administered by the patient and are injected or infused while you are getting physician, 
hospital outpatient, or ambulatory surgical center services. The provider billed in the amount of $3,463.23 and 
the allowed amount is $2,308.83. $2,308.83 x 20% = $461.77. Therefore, results in the total cost sharing 
amount of $461.77. 
 
 
 
 You have been asked to pay a 20% coinsurance for Part B drugs. This item/service falls within the Medicare 
Part B prescription drugs 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 Part B 
drugs on May 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transthoracic echocardiography (TTE) provided on January 
13, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a transthoracic echocardiography (TTE). You say that the test report is supposed 
to furnish within 24 hours, which does not allow you to have ample time to verify eligibility and process 
authorization beforehand. The Plan denied your request. The Plan says services from non-participating 
providers are not covered under the Plan unless they are authorized before the services are provided. 
 
  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 a transthoracic echocardiography (TTE) provided 
on January 13, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on April 
30, 2022, to May 05, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you think the claim 
should be paid by the Plan. 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 $100 
copayment for an inpatient hospital stay. 
 
You have been asked to pay a $100 copayment for an inpatient hospital stay. This item/service falls within the 
an inpatient hospital stay benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for an inpatient 
hospital stay provided on April 30, 2022, to May 05, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the casirivimab and imdevimab injections 
provided on January 1, 2022. 
 
You asked the Plan to waive the cost share for the injections. You say that none of this was in your contract. 
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 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay a 20% coinsurance for Part B drugs for the injections. This item/service falls 
within the Medicare Part B Prescription Drugs 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 
cost share for the casirivimab and imdevimab injections provided on January 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair chair lift. 
 
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit, as it is not primarily medical in nature. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair chair lift.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 2, 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 procedure code 81529 is not supported. 
 
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 81529 is oncology (cutaneous melanoma), mRNA, gene 
expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-
fixed paraffin-embedded tissue, algorithm reported as recurrence risk, including likelihood of sentinel lymph 
node metastasis. 
 
We find that CPT code 81529 is not supported in the medical record. Specifically, the file shows that the 
specimen was not collected on the billed date of service. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered on June 2, 2022.