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

 
We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, 
non-emergency transport (A0428, A0425) provided on August 25, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $270 
copayment for each Medicare-covered one-way trip via ground ambulance.  
 
 
 You have been asked to pay a $270 copayment for the Medicare-covered one-way ground ambulance trip 
provided. 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 the ambulance service, basic life support, non-
emergency transport (A0428, A0425) provided on August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are prediabetic. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gait training therapy (97116) rendered by the out-of-
network (OON) provider on September 15, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the gait training therapy (97116) rendered by the out-of-network (OON) provider on 
September 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for an echocardiogram provided on November 
5, 2021. 
 
You asked the Plan to lower the copayment for an echocardiogram. You say that you were told the copayment 
would be lower than what was charged. The Plan denied your request. The Plan says the proper copayment 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 $350 
copayment for all other outpatient hospital services.  
 
  You have been asked to pay a $350 copayment for an echocardiogram. An echocardiogram falls within 
Outpatient hospital services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to lower the copayment for an 
echocardiogram provided on November 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis (81455) provided May 
16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that it is the responsibility of the referring 
physicians to determine medical necessity for testing. The Plan denied your request. The Plan says genetic 
testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical 
management of the patient and will be denied automatically as not medically necessary. 
 
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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that Medicare covers targeted genomic sequence testing for 
recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. Not been previously tested using 
NGS for the same cancer and genetic content. The review indicates that the medical records provided did not 
meet the requirements listed in the LCD for Medicare coverage. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for targeted genomic sequence analysis (81455) provided May 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (82310, 82728, 83540, 83550, 83970, 
84100) provided on June 16, 2021. 
 
You asked the Plan to pay for laboratory testing. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory testing (82310, 82728, 83540, 83550, 83970, 84100) provided on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for lower intestinal endoscopic procedures 
(00811) provided on August 7, 2021. 
 
You asked the Plan to pay for the anesthesia for lower intestinal endoscopic procedures (00811). You say that 
the medical records support the medical necessity, and the services should be linked to the hospital charges. 
The Plan denied your request. The Plan says the billed services have already been paid. 
 
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 00811 is anesthesia for lower intestinal endoscopic 
procedures, endoscope introduced distal to duodenum; not otherwise specified. 
 
  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 anesthesia for lower intestinal endoscopic procedures 
(00811). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for 
coverage. Our reviewer found that the documentation supports a colonoscopy was performed on the billed date 
of service. No additional procedures were performed to support additional units of CPT code 00811. 
 
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 anesthesia for lower intestinal endoscopic procedures (00811) have not been 
met. Therefore, we decided that the Plan does not have to pay for the anesthesia for lower intestinal endoscopic 
procedures (00811) provided on August 7, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the inpatient skilled nursing facility (SNF) 
care provided from October 1, 2021, through October 12, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
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 50% 
coinsurance per day, for days 1 to 100 for skilled nursing facility care rendered by an out-of-network provider.  
 
  
You have been asked to pay $3,270.48 (Plan allowed amount of $6,540.97 x 50% coinsurance) for the skilled 
nursing facility care rendered by an out-of-network provider. 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 the inpatient skilled nursing facility (SNF) care provided from October 1, 2021, through October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture treatment provided from June 23, 2021, through 
June 28, 2021. 
 
You asked the Plan to pay for acupuncture treatment. The Plan denied your request. The Plan says acupuncture 
is not a covered benefit for pain unrelated to the back. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, acupuncture is not a covered benefit for pain 
unrelated to the back. Therefore, we decided that the Plan does not have to pay for acupuncture treatment 
provided from June 23, 2021, through June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for analysis of the methylation status of gene markers for 
detection of prostate cancer (81551) provided on November 23, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are the sole source provider for the 
ConfirmMDx test. Therefore, this test cannot be performed at your contracted laboratory. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 analysis of the methylation status of gene markers 
for detection of prostate cancer (81551) provided on November 23, 2021 by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient specialist visit on September 
28, 2021. 
 
You asked the Plan to waive the copayment for an outpatient specialist visit. You say that you would like to 
have the copayment overturned. The Plan denied your request. The Plan says the copayment 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 $35 
copayment for an outpatient specialist visit.  
 
You have been asked to pay a $35 copayment for an outpatient specialist visit. An outpatient specialist visit 
falls within the Outpatient Hospital Services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an outpatient specialist visit on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for Lyft rides provided on February 2, 2021. 
 
You asked the Plan to reimburse you for Lyft rides. The Plan denied your request. The Plan says the Evidence 
of Coverage has no separate supplemental transportation benefit that would cover the Lyft rides. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. The file shows that your Plan has no 
separate supplemental transportation benefit that would cover the Lyft rides. Therefore, we decided that the 
Plan does not have to reimburse you for Lyft rides provided on February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-chek diabetic lancets. 
 You asked the Plan to pre-approve the Accu-chek lancets. You say that these lancets are medically necessary. 
The Plan denied your request. The Plan says this brand is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. The requested Accu-chek lancets are produced by Roche. Only 
diabetic test supplies by Abbott or LifeScan are covered. Based on this information, we decided that Medicare 
rules for coverage of the Accu-chek lancets have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Accu-chek diabetic lancets.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapeutic services (97110) provided on 
November 4, 2021. 
 
You asked the Plan to waive the copayment for therapeutic services. You say that you did not know it was $35 
each time you went, and you thought your copayment was supposed to be $10. The Plan denied your request. 
The Plan says you were 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 $35 
copayment for Medicare-covered therapy visit.  
 
You have been asked to pay a $35 copayment for therapeutic services. Therapeutic services fall within the 
outpatient rehabilitation 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 
therapeutic services (97110) provided on November 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Portable X-Ray provided on January 28, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a Portable X-Ray. You say that We are billing based on Medicare Guidelines. A 
Portable X-ray was done in a skilled nursing facility  Palazzo Post-Acute but the patient is under custodial 
services only. The Plan denied your request. The Plan says Services were not urgent emergent and provided by 
a noncontracted provider at a non-contracted facility without prior 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 Portable X-Ray provided on January 28, 2021 by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (82310, 82728, 83540, 83550, 83970, 
84100) provided on September 15, 2021. 
 
You asked the Plan to pay for laboratory testing. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory testing (82310, 82728, 83540, 83550, 83970, 84100) provided on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on October 6, 2021. 
 
You asked the Plan to pay for the eyeglasses. You say that even though this patient has a vision plan for glasses 
and routine visit, this claim is considered medical due to cataract surgery and Medicare's guidelines for post-operative glasses. The Plan denied your request. The Plan says the service obtained by the member was 
rendered by a provider who is not under contract with the vision provider or the Plan. 
 
The Plan contract says covered eyeglasses after cataract surgery includes standard frames and lenses as defined 
by Medicare. The Plan contract also says that all eyeglasses and contact lenses, including eye refractions to 
determine changes in your vision and/or the need for eyeglasses or contact lenses, even if you have a cataract 
surgery, must be obtained through a Plans vision provider 
 
We looked at the file and the Plan's rules. The file shows that the eyeglasses were not obtained through the 
Plans vision provider. 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 provided 
on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cxbladder Detect, multianalyte assay (0012M). 
 
You asked the Plan to pay for Cxbladder Detect. You say that you believe the combination of the medical 
records and strong peer-reviewed publications and Novitas/CMS, LCD coverage is sufficient evidence to rule 
in your favor and provide payment for this claim. The Plan denied your request. The Plan says a review of the 
medical literature and clinical practice guidelines does not support the clinical utility of CxBladder. 
 
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 Cxbladder Detect. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical records and scientific literature do not support medically necessary of CxBladder 
testing. CxBladder is considered experimental/investigational as a screening test for urothelial cancer. 
Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the 
results of Cxbladder testing. Urinary biomarker tests such as CxBladder give significant false-negative results 
in patients with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-
stage and low-grade tumors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cxbladder Detect have not been met. Therefore, we decided that the Plan does 
not have to pay for Cxbladder Detect, multianalyte assay (0012M).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Freestyle Libre continuous glucose monitor sensor kit 
(K0553) provided on September 24, 2021. 
 
You asked the Plan to pay for a Freestyle Libre sensor kit. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical 
equipment have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain proof of delivery nor relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for a Freestyle Libre 
continuous glucose monitor sensor kit (K0553) provided on September 24, 2021.