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

 
We decided that the Plan does not have to pay for New Patient Preventive Medicine Services provided on 
December 29, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for New Patient Preventive Medicine Services. You say that the provider is an in-
network provider. The claim was denied in error for out of network. Please reprocess the claim for full 
reimbursement. 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 New Patient Preventive Medicine Services 
provided on December 29, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 10, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the lab work was needed to further evaluate 
the enrollee. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
was no referral from an in-network provider or an approved authorization. Also, the service rendered was not 
urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 10, 
2022, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
have therapy or complex skilled nursing needs. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our physician reviewer found 
that the enrollee was admitted to the acute hospital with a lumbar compression fracture and an acute kidney 
injury. She is medically stable and has no medical complexity. She does not need close supervision by a 
rehabilitation physician 3 times per week for the ongoing management of any active or acute exacerbations of 
chronic medical conditions.  At the functional level, the enrollee does not need 3 hours a day five days a week of IRF therapies with 
interdisciplinary management. The complexity of her nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp (A9270). 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that the enrollee has significant mobility 
deficits requiring transport with a wheelchair using a portable ramp. The ramp is a medical necessity for her in 
order to be transported beyond the confines of her home including doctor's appointments. The Plan denied your 
request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp (A9270).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
October 29, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the provider did not treat your 
condition. 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 $90 
copayment for each emergency room visit.  
 
The record shows you were evaluated and treated for dysphagia. Therefore, you have been asked to pay a $90 
copayment for the ER visit. The ER visit falls within the Emergency 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 an emergency room (ER) visit provided on October 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 8, 2019, 
through December 6, 2019, billed with code 2BFMS. 
 You asked the Plan to pay for the home health services as billed. You say that this was billed correctly and 
should be paid. The Plan denied your request. The Plan says a subset of the rendered physical and occupational 
therapy visits were provided without an official re-assessment being performed by the therapist. As such, these 
visits cannot be billed, which reduces the payable code to 2BFL2. 
 
The Plan must follow Medicare rules. Medicare rules say that skilled services provided during a home health 
plan of care must be medically necessary. Medical necessity is ensured, in part, with periodic therapy 
assessments every 30 days which indicate that skilled care remains necessary.  
 
We looked at the file and Medicare rules. We find that the denied visits were provided before a re-assessment 
by the therapist was performed. Based on this information, we decided that Medicare rules for coverage of the 
home health services as billed have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from October 8, 2019, through December 6, 2019, billed with code 2BFMS.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
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 24 one-way 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 routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 8, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that you submitted documentation for review. The Plan 
denied your request. The Plan says the rendering provider is an OON provider and there was no referral from 
an in-network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on February 8, 2022, by an 
OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 10, 
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 the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided to the enrollee on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the attached claim(s) were denied payment because 
either there was no authorization on file and the service meets medical necessity or the authorization was not 
obtained before services were provided. The Plan denied your request. The Plan says the service is not covered 
for out-of-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 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 February 10, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Chiropractic Care provided on January 25, 2022 to February 
14, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Chiropractic Care. You say that you would like to appeal the denial of the claim. 
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 Chiropractic Care provided on January 25, 2022 to 
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 provided on January 14, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the ordering provider is an in-network 
provider, and the specimen was sent to your lab. The Plan denied your request. The Plan says the rendering and 
the 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 January 14, 
2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis service to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve dialysis service to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 
dialysis service 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 compression stockings. 
 You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are 
medically necessary. The Plan denied your request. The Plan says the enrollee has a history of lower extremity 
venous insufficiency, but he does not currently have open venous stasis ulcers. Therefore, coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code [enter 
HCPCS code] are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say 
that compression bandages and gradient compression wraps are covered only when they are used as dressings 
over a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Magnetic resonance imaging (MRI) on 
May 5, 2021. 
 
You asked the Plan to waive the copayment for Magnetic resonance imaging (MRI). You say that you would 
like to appeal the cost share. The Plan denied your request. The Plan says the cost share applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $300 copayment for Magnetic resonance imaging (MRI).  
 
The enrollee has been asked to pay a $300 copayment for Magnetic resonance imaging (MRI). Magnetic 
resonance imaging (MRI) falls within the Outpatient diagnostic tests and therapeutic services and supplies 
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for Magnetic resonance imaging 
(MRI) on May 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a cardiovascular stress test, technetium 
injection, and regadenoson injection provided on December 2, 2021. 
 
You asked the Plan to waive the coinsurance for the stress test and injections. You say that the test only has a 
$25 copayment. 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 non-radiological tests, such as stress tests.  
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each Part B drug. 
 
Service/Drug Allowed Amount Coinsurance 
Cardio Stress Test $73.58 $7.36 (10%) 
Technetium $244.42 $48.88 (20%) 
Regadenoson $262.04 $52.41 (20%) 
Total:  $108.65 
 
You have been asked to pay $7.36 for the stress test, which is 10% of the allowed amount. The stress test falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also 
been asked to pay $48.88 and $52.41 for the injections, which are both 20% of the allowed amount. The 
injections fall within the Medicare Part B Prescription Drugs benefit category. The total for the services is 
$108.65. 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 cardiovascular stress test, technetium 
injection, and regadenoson injection provided on December 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary services provided on October 19, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that this is to appeal this claim that was processed 
out of network and denied for no authorization. 
Please consider that at the time of visit neither the member nor the provider was aware that the provider is out 
of network with the members plan. 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 Domiciliary services provided on October 19, 
2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest and of 
the abdomen/pelvis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have a history of six months of 
back pain and spasms described as starting at right shoulder blade and radiating to top of buttock, worse at 
night when lying down. An x-ray of the thoracic spine showed moderate mid-thoracic and mild lower thoracic 
degenerative disc disease but was otherwise unremarkable. There is no documentation that you have fully 
exhausted conservative methods for the pain, including physical therapy. There are also no objective signs or 
symptoms of abdominal/pelvic or chest symptoms or red flags to justify advanced imaging. The CT scans are 
therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the chest and of the abdomen/pelvis.