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

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital observation provided 
on August 02, 2021, to August 03, 2021. 
 
You asked the Plan to waive the copayment for an outpatient hospital observation. You say that you can not 
afford to pay the 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 $295 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $295 copayment for an outpatient hospital observation. This item/service falls 
within the outpatient hospital observation 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 outpatient hospital observation provided on August 02, 2021, to August 03, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says these items are not a covered 
benefit under the enrollees contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Additionally, you had requested compression stockings identified with code 
A9270 which is defined as a non-covered item by Medicare. Therefore, we decided that the Plan does not have 
to pre-approve compression stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids (V5258). 
 
You asked the Plan to pre-approve the hearing aids. You say that you have tried having your current hearing 
aids cleaned, but you still can barely hear with them, and the issues persist. You also say that you would like 
the Plan to approve new hearing aids. The Plan denied your request. The Plan says you received hearing aids 
on October 5, 2021, and your hearing aid benefit has been used. The Plan also says that you are not eligible to 
obtain new hearing aids until October 5, 2023. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only every two years.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-
approve hearing aids (V5258).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abdominoplasty (15847). 
 
You asked the Plan to pre-approve the abdominoplasty. You say that this service is medically necessary. The 
Plan denied your request. The Plan says this procedure is cosmetic and non-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 abdominoplasty. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record provided indicates that the abdominoplasty is for cosmetic purposes of repairing a 
diastasis and relocating the umbilicus. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service 
 
 
 
 
 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 abdominoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an abdominoplasty (15847).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary, and the 
claim should not be denied based on timely filing rules. The Plan denied your request. The Plan says you did 
not timely file this claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until May 10, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for lab services provided on May 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient surgery to be provided by an OON provider. 
 
You asked the Plan to pre-approve outpatient surgery. You say that you are requesting the referral be 
authorized. The Plan denied your request. The Plan says this service can be provided within the Plan's in-
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 
outpatient surgery to be provided by an OON provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically 
ill or critically injured patient; first 30-74 minutes (99291) provided February 5, 2022 to February 7, 2022 
 
You asked the Plan to pay for the critical care services. You say that you are submitting the requested 
documentation to support CPT code 99291. Please review and reprocess for payment. The Plan denied your 
request. The Plan says the records do not support the service 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted 
did not support critical care visit of 30-74 minutes was performed. The documentation does not include the 
time spent providing this service. The Plan made multiple attempts to obtain the additional information from the provider without success. Based on this information, we decided that Medicare rules for coverage of the 
critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the 
critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes 
(99291) provided February 5, 2022 to February 7, 2022
Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to waive the $890 copayment for a SNF stay. We decided that the Plan does not 
have to waive the $3,738 copayment for a SNF stay.  
 
You asked the Plan to waive the copayment for a Skilled Nursing Facility (SNF) stay from January 1, 2022, to 
January 31, 2022. You say that the enrollee should not be responsible to pay this. The Plan says that the cost 
share has been applied correctly. 
 
 
 We decided that the Plan has to waive the $890 copayment for a SNF stay.  
 
The Plan follows Medicare rules. Medicare rules say that a plan must disclose to its enrollees in clear, accurate 
terms all cost-sharing information (such as copayments, deductibles, and coinsurance). 
 
We looked at your request, the file, and rules. The Plan did not include a record showing the date of admission; 
therefore, the Plan has not shown the admission date is correct. Therefore, we decided that the Plan has to 
waive the $890 copayment for a SNF stay.  
 
We also decided that the Plan does not have to waive the $3,738 copayment for a SNF stay. 
 
The Plan follows Medicare rules. Medicare rules say that a plan must disclose to its enrollees in clear, accurate 
terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The Plan has correctly 
applied the cost share for 21 days of SNF care.  Therefore, we decided that the Plan does not have to waive the 
$3,738 copayment ($178/day x 12days = $3,738) for a SNF stay.  
 
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 laboratory services (88305, 88312) provided on June 3, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not 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 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 (88305, 88312) provided on 
June 3, 2022 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you need transportation because you 
have conditions in your legs and cannot walk. You also say that you have no means of transportation. The Plan 
denied your request. The Plan says you have used 24 one-way trips of the 24 one-way trips covered by the 
health plan for the year 2022. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider. 
 
You asked the Plan to pre-approve an office visit. The Plan denied your request. The Plan says this service can 
be safely rendered 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 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 
an office visit to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Onyfix nail correction treatment. 
 
You asked the Plan to pre-approve Onyfix nail correction treatment. The Plan denied your request. The Plan 
says Onyfix nail correction treatment is not a covered benefit. 
 
The Plan contract covers Podiatry services.  
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover Onyfix nail correction 
treatment. Therefore, we decided that the Plan does not have to pre-approve Onyfix nail correction treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on April 4, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not 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 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 (99214) provided on April 4, 2022 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DME supplies (A6212, A6213, A6214, A6220) provided on 
May 25, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the DME supplies. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not 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 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 DME supplies (A6212, A6213, A6214, A6220) 
provided on May 25, 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 total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you are requesting a bed more 
accommodating to regain maximum function for independent living. The Plan denied your request. The Plan 
says the requested bed does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 7, 2022, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81351, 81408, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
should have been billed under a single Current Procedural Terminology (CPT) code. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 7, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81351, 81408, and 
81479.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pneumatic compressor, segmental home model without 
calibrated gradient pressure and associated additions to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve Pneumatic compressor, segmental home model without calibrated gradient 
pressure and associated additions. You say that there is no in-network provider that carries the device the 
provider has requested for you. The Plan denied your request. The Plan says they have provided the name and 
phone number for two in-network providers that can provide the recommended device. 
 
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 
Pneumatic compressor, segmental home model without calibrated gradient pressure and associated additions 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 pre-approve shower chair repairs. 
 
You asked the Plan to pre-approve shower chair repairs. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says a shower chair is not a covered benefit under the 
enrollee's contractual policy or by Medicare; therefore, shower chair repairs are also non-covered.  
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While shower chair repairs may be appropriate in this case, neither the Plan nor Medicare offers coverage of a 
shower chair; thus, the requested repairs for a shower chair would also be non-covered. Therefore, we decided 
that the Plan does not have to pre-approve shower chair repairs.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88305) provided on December 22, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not 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 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 pathology services (88305) provided on December 
22, 2021 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 portable oxygen concentrator rental to be provided by 
an OON provider. 
 
You asked the Plan to pre-approve a portable oxygen concentrator rental. You say that you need oxygen at all 
times and need to have a portable oxygen concentrator for when you have doctor's appointments. The Plan 
denied your request. The Plan says you have been approved this service through an equally qualified in-
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
a portable oxygen concentrator rental to be provided by an OON provider.