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

 
We decided that the Plan does not have to pay for the laboratory services provided on December 7, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the rendering provider sent the test to your 
laboratory, and you would like the claim reprocessed for payment. 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 laboratory services provided on December 7, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for portable oxygen supply provided on 
November 30, 2021. 
 
You asked the Plan to waive the coinsurance for the portable oxygen supply. You say that you should not have 
to pay the coinsurance due to your COVID-19 diagnosis. 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 10% 
coinsurance for other durable medical equipment (DME), including oxygen equipment.  
 
You have been asked to pay $6.17, which is 10% of the allowed amount for the portable oxygen supply 
($61.69 allowed amount x 10% coinsurance = $6.17). Please note that there is no cost share waivers in effect 
for the date of service. The portable oxygen supply falls within the Durable Medical Equipment (DME) and 
Related Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for portable oxygen 
supply provided on November 30, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on July 21, 
2021. 
 
You asked the Plan to pay for the hospital care. You say that the service should be paid. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 20, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care 
(99232) provided on July 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of gallbladder (47600) and repair bowel opening 
of small or large intestine (44626) provided on February 7, 2022, by a registered nurse first assistant. 
 
You asked the Plan to pay for the surgical services. You say that there were no in-network providers available 
for this service. The Plan denied your request. The Plan says this provider specialty does not have the capacity 
to bill directly for the services rendered. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the removal of gallbladder (47600) 
and repair bowel opening of small or large intestine (44626) provided on February 7, 2022, by a registered 
nurse first assistant.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hearing exam and office visit (92504, 
99213) provided on February 1, 2022. 
 
You asked the Plan to waive the copayment for the hearing exam and office visit. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for Physician/Practitioner Services, Including Doctors Office Visits and a $20 copayment for 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies. 
 
You have been asked to pay a $20 copayment for the hearing exam and a $25 copayment for an office visit. 
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 hearing exam and office visit 
(92504, 99213) provided on February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional anesthetic injection (64415) provided on 
February 24, 2021. 
 
You asked the Plan to pay for an additional anesthetic injection. You say that this was billed correctly. The 
Plan denied your request. The Plan says this was previously paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that a second unit of CPT code 64415 is not supported in the medical record. The medical record only 
supports one unit of CPT code 64415, which was previously billed and paid. Based on this information, we 
decided that Medicare rules for coverage of an additional anesthetic injection have not been met. Therefore, we 
decided that the Plan does not have to pay for an additional anesthetic injection (64415) provided on February 
24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Breo Ellipta inhaler. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee has used this medication 
since 2020. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drug benefits. 
 
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 Breo Ellipta inhaler.  
 
Benefits for self-administered drug 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on January 07, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you were under the impression this 
was covered, and you do not have financial means to pay the bill. 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 $250 
copayment per one-way trip for ambulance services. Covered ambulance services include fixed wing, rotary 
wing, and ground ambulance services, to the nearest appropriate facility that can provide care if they are 
furnished to a member whose medical condition is such that other means of transportation could endanger the 
persons health or if authorized by the plan. 
 
You have been asked to pay a $250 copayment for ambulance. Ambulance 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 on January 07, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
current acute care hospital. All medically necessary care is being provided in the current acute care setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve the home health skilled nursing visits (CPT code G0299 x2). 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says that the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our physician 
reviewer found clinical documentation shows multiple uncontrolled comorbidities, the enrollee with cognitive 
impairment and functional impairments; thus, the enrollee would require the medical monitoring and treatment 
from a professional nurse. Two (2) additional home health nursing visits are 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 home health services have been met. Therefore, we decided that the Plan has to 
pre-approve the home health skilled nursing visits (CPT code G0299 x2). 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 next generation sequence (NGS) testing panel provided 
on 
 
You asked the Plan to pay for the NGS testing panel. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels that include testing for the FANCC gene 
are not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the NGS testing panel provided 
included testing for the FANCC gene. This means the entire panel is not covered. Based on this information, 
we decided that Medicare rules for coverage of the NGS testing panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the next generation sequence (NGS) testing panel provided on
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laparoscopy, surgical, repair, ventral, umbilical, spigelian 
or epigastric hernia (includes mesh insertion, when performed) (49653) provided February 25, 2022. 
 
You asked the Plan to pay for the surgical procedure. You say that due to network insufficiency, the out of 
network provider was the only assistant at the time of the procedure and rendered services specifically 
requested by the in-network primary physician and in-network facility. The Plan denied your request. The Plan 
says this provider was not certified/eligible to be paid for this procedure/service on this date of service. 
Medicare does not recognize you as a physician or non-physician practitioner. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed) (49653) provided 
February 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
February 24, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says the services does 
not meet Medicare NCD/LCD criteria 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test 
(0037U) provided February 24, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet blocks. 
 
You asked the Plan to pre-approve facet blocks. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who meet specific criteria. 
 
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 facet blocks. Our reviewer says that the services are not medically necessary. Our physician reviewer found the notes do not 
explain why you cannot receive radiofrequency ablation (RFA) therapy. The request for repeat blocks does not 
meet LCD criteria and therefore, the request is considered medically unreasonable and unnecessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet blocks have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet blocks.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 28, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this claim is not a duplicate and is supported 
in the medical record. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 28, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve a MyoPro Motion G orthosis. You say that this device is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested device is considered 
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 a MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient literature in the peer-reviewed publications to assess 
safety, efficacy, long term outcomes or patient management associated with the use of the MyoPro Orthosis for 
upper extremity paralysis/paresis from conditions such as multiple sclerosis or other 
neuromuscular/neurological disease or injury. Therefore, the requested orthosis is not reasonable and necessary 
for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a MyoPro Motion G orthosis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Motion G orthosis.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has diabetes and cannot take care of 
their wounds. The Plan denied your request. The Plan says the enrollee is not yet ready for discharge from the 
hospital, and therefore, the enrollee can receive the needed services while remaining in the hospital. The Plan 
states transfer to a SNF is not medically necessary at this time. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our physician reviewer 
found the clinical documentation states that the enrollee's wound care and functional needs would be met with 
intermittent skilled nursing/therapy services thus daily services in a SNF are not medically necessary. SNF 
criteria not met per clinical documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit provided 
on January 18, 2022. 
 
You asked the Plan to waive the copayment for a hospital outpatient clinic visit. The Plan denied your request. 
The Plan says the claim processed correctly for outpatient services. 
 
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 $275 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $275 copayment for a hospital outpatient clinic visit. The hospital outpatient 
clinic visit falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 hospital 
outpatient clinic visit provided on January 18, 2022.