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

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 6, 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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on January 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from June 16, 
2021, to July 15, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says home health services under a plan of care are paid based on a 30-day period of care. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
 
 
 
 
 The dates of service were not reported correctly in this case. The through date of July 15th is billed as the 30th 
day, when it would be the 29th day of care. 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 home 
health services provided to the enrollee from June 16, 2021, to July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a GEL-ONE injection provided on 
October 11, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that the provider informed you the cost 
would be covered. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 $552, which is 20% of the allowed amount for the injection ($2,760 allowed 
amount x 20% coinsurance = $552). The injection 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 a GEL-ONE injection provided on October 11, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on February 14, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you believe the service was billed 
incorrect and would like to appeal the denied claim. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no approved authorization. 
 
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 specialist office visit provided on February 14, 
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 laboratory services rendered on August 5, 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 a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8 and the file 
shows the services were not performed to a hospital inpatient. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on August 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided to the enrollee from August 
7, 2020, to August 28, 2020. 
 
You asked the Plan to pay for the services. You say that the hospital medication administration record shows 
0.9% sodium chloride infusion, administered intravenously. The Plan denied your request. The Plan says the 
clinical documentation received does not support the coding of parenteral/IV feeding. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
support a diagnosis/use of parenteral/IV feeding in this case, as the administration of 0.9% sodium chloride at a 
rate of 42 mL/hr does not qualify as parenteral/IV feeding. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing services provided to the enrollee from August 7, 2020, to August 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a blood smear (85060) provided on December 5, 2021. 
 
You asked the Plan to pay for a blood smear. You say that this was medically necessary. The Plan denied your 
request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients. 
 
We looked at the file and Medicare rules. The record indicates that the enrollee was a hospital outpatient at the 
time of service. Based on this information, we decided that Medicare rules for coverage of a blood smear have 
not been met. Therefore, we decided that the Plan does not have to pay for a blood smear (85060) provided on 
December 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee surgery received on March 6, 2020. 
 
You asked the Plan to pay for the surgery. You say that this should be paid for. The Plan denied your request. 
The Plan says the deductible had not been met. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to covered medical services.  
 
The item or service you asked the Plan to pay for falls within the benefit category for covered medical services. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to covered medical services. This cost sharing is a contractual obligation that had not been met at the 
time the surgery was received on March 6, 2020. Therefore, we decided that the Plan does not have to pay for 
knee surgery received on March 6, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the deductible for the diagnostic ultrasound provided on February 17, 
2022. 
 
You asked the Plan to waive the deductible for the diagnostic ultrasound. You say that you would like 
reconsideration because the deductible should not apply to this service. The Plan denied your request. The Plan 
says that the ultrasound is not preventive, so the deductible applies. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $25 copayment for Medicare-covered outpatient 
diagnostic procedures and tests.  
 
The Plan says you must pay a $125.07 towards your deductible for the diagnostic ultrasound. Based on the Plan 
contract, however, you cannot be asked to pay more than a $25 copayment for the diagnostic ultrasound. Please 
note, there is no indication in the EOC that the deductible would apply to outpatient diagnostic procedures and 
tests. Therefore, we decided that the Plan has to waive the deductible for the diagnostic ultrasound provided on 
February 17, 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 genetic testing services provided to the enrollee on 
December 20, 2021.  
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says in addition to single gene testing, panels that include the FANCC gene are statutorily excluded 
service. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the case file does not contain documentation that demonstrates that the enrollee in this case has not been 
previously tested with the same test using NGS for the same cancer genetic content, and has decided to seek 
further cancer treatment which will be impacted by the Oncotype MAP Pan-Cancer Tissue Test. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for genetic testing services provided to the enrollee on December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 17, 2021. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says you are required to 
use doctors that are a part of your health Plan. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmological services: medical 
examination and evaluation, with initiation or continuation of diagnostic and treatment program (code 92014) 
provided on January 4, 2022, and February 12, 2022. 
 
You asked the Plan to waive the copayment for ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program. The Plan denied your request. 
The Plan says the claim processed 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 Vision Care, for eye exam to diagnose and treat diseases of the eye through a non-contract 
vision specialist.   
You have been asked to pay a $40 copayment for ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program. The ophthalmological services: 
medical examination and evaluation, with initiation or continuation of diagnostic and treatment program falls 
within the Vision Care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic 
and treatment program (code 92014) provided on January 4, 2022, and February 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmology visit= provided on March 14, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON ophthalmology services. You say that this should be covered due to 
medical necessity. The Plan denied your request. The Plan says these services were available from a network 
provider, and no authorization was requested for OON care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The provider at issue in this case is not a network provider with the Plan. 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 OON ophthalmology services. Our reviewer says that the OON services 
provided are not shown to be medically necessary only from this provider. Our physician reviewer found based 
on the medical records provided, there is no documentation that the out-of-network ophthalmology visit on 
03/14/2022 at issue in this case was medically reasonable and necessary as an emergency, out of area urgent 
care or pre-approved care. Provided records do not document any emergent or urgent issues; records report the 
enrollee's vision was unchanged at the time of this visit with no new issues reported and no new treatment 
recommended or provided.  
 
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 OON ophthalmology services have not been met.  
 
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 pay for the OON ophthalmology services. Therefore, we decided 
that the Plan does not have to pay for the ophthalmology visit= provided on March 14, 2022, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses (V2100, V2025) provided February 3, 2022 
 
You asked the Plan to pay for the eyeglasses. You say that the eyeglasses should be covered. The Plan denied 
your request. The Plan says the correct payment was issued. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan provides a $200 allowance towards covered eyewear. 
 
We looked at the file and the Plan's rules. The plan applied the $200 benefit to the eyewear (total cost of $378). 
The plan also applied a 20% discount for using in-network providers. This leaves the enrollee's share at 
$142.40. The correct cost-sharing was applied. Based on this information, we decided that the Plan's rules for 
coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for 
eyeglasses (V2100, V2025) provided February 3, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient surgery procedure (51798, 52000) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an outpatient surgery procedure. You say that you have an enlarged prostate 
with large stones accompanied by blood in your urine. You also say you currently have a foley catheter and in 
severe pain. You need to have surgery to relieve pressure as soon as possible. The Plan denied your request. 
The Plan says services must be received by in-network Plan providers. There are in-network providers 
available with the Plan. 
 
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 outpatient surgery procedure (51798, 52000) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for outpatient physical therapy services provided from 
February 10, 2022, to March 4, 2022. 
 
You asked the Plan to waive the coinsurance for physical therapy. You say that you qualify for a dual 
enrollment policy that has zero cost-sharing. The Plan denied your request. The Plan says that the cost-sharing 
amounts you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $0 copayment for outpatient rehabilitation services.  
 
The Plan says you must pay $123.03, which is 20% coinsurance for physical therapy. Based on the Plan 
contract, however, you cannot be asked to pay more than $0 copayment for physical therapy. Therefore, we 
decided that the Plan has to waive the coinsurance for outpatient physical therapy services provided from 
February 10, 2022, to March 4, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you spoke with the provider representative, and the 
representative said you do not need a prior authorization. The Plan denied your request. The Plan says the 
rendering provider is a non-participating provider, and there is no referring provider involved in these services. 
The Plan also says they did not authorize any services for this 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 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 January 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a foam sclerotherapy injection provided on 
November 19, 2021. 
 
You asked the Plan to waive the copayment for the injection. You say that you were informed that a different 
procedure was to be done. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each specialist visit, including surgery services furnished in a physician's office.  
 
You have been asked to pay a $40 copayment for the injection. The injection falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a foam sclerotherapy injection provided on November 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
January 26, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the cost is too high 
and there should be a difference between emergency and non-emergency transport costs. 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 $225 
copayment for each one-way ambulance trip.  
 
 
 
 
 
 
 You have been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation 
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 
ambulance transportation provided on January 26, 2022.