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

 
We decided that the Plan does not have to pay for endovenous ablation therapy provided on August 17, 2021, 
by an OON provider. 
 
You asked the Plan to pay for the endovenous ablation therapy. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not approved in advance. 
 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 endovenous ablation therapy provided on August 
17, 2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DetermaRx predictive classifier testing provided on 
August 2, 2021. 
 
You asked the Plan to pay for the DetermaRx testing. You say that this is a medically necessary test. The Plan 
denied your request. The Plan says it was confirmed with the treating physician that this testing was not 
ordered. 
 The Plan follows Medicare rules. The rules say that testing such as DetermaRx may be covered when the 
criteria listed in the Medicare rules section are met. 
 
We looked at the file and Medicare rules. The documentation does not address whether the patient is 
sufficiently healthy for chemotherapy, nor that it is being considered. Based on this information, we decided 
that Medicare rules for coverage of the DetermaRx testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the DetermaRx predictive classifier testing provided on August 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on April 15, 2021. 
 
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says the 
member only has hearing benefits with in-network providers. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only from any network hearing or hearing aid provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by a network 
hearing or hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the 
hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing 
aids provided on April 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transport (A0428) provided on 
January 10, 2022. 
 
You asked the Plan to pay for the ambulance transport. You say that the enrollee has a spinal fracture and 
requires a special wheelchair or stretcher to get down to the vehicle and get to an appointment.  The Plan denied your request. The Plan says while there is documentation that the enrollee cannot ride in a 
regular car, there is no documentation that they cannot be transported in a stretcher van or wheelchair van. The 
requested ambulance transport is not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance transport. Our reviewer says 
that the ambulance services were not medically necessary in this case. Our physician reviewer found that the 
enrollee was transported via ambulance for a non-emergent scheduled office appointment. It was reported that 
the enrollee could not effectively walk down the stairs due to the pain. He was transported via stretcher down 
the stairs to the ambulance. No treatment was needed or receiving during transport. Vitals were stable. There is 
insufficient documentation to support that all other means of transportation (such as stretcher van, wheelchair 
van) were contraindicated for this enrollee on the date in question. The documentation does not support that the 
enrollee required the expertise, services and lifesaving and life sustaining equipment that only a fully-equipped 
ambulance can provide for safe transport. The documentation does not support that these services were 
medically reasonable and 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 the ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pay for non-emergent ambulance transport (A0428) provided on January 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (codes 82728, 83540, and 83550) provided on 
November 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment of these services. The Plan denied your request. The Plan says payment for these lab services is 
bundled into the payment to the End Stage Renal Disease facility. The Plan says that because these lab services 
are the responsibility of the patient's dialysis facility, this claim should not have been submitted to the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that that all end-stage renal disease (ESRD)-related 
laboratory services are included in the ESRD Prospective Payment System base rate and must be reported by 
the ESRD facility and are not separately paid.  These lab services were provided to an ESRD patient and are 
therefore not separately paid. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (codes 82728, 83540, and 83550) provided on November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient cardiac rehabilitation; with continuous ECG 
monitoring provided from October 5, 2021, through October 28, 2021. 
 
You asked the Plan to pay for outpatient cardiac rehabilitation; with continuous ECG monitoring. The Plan 
denied your request. The Plan says 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 Plan says that the Plan has also 
determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 outpatient cardiac rehabilitation; with continuous ECG 
monitoring provided from October 5, 2021, through October 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an arthrocentesis, aspiration and/or 
injection, major joint or bursa (20610) provided on November 12, 2021. 
 
You asked the Plan to waive the copayment for an arthrocentesis, aspiration and/or injection, major joint or 
bursa. You say that you told the provider office that this was not within a procedure room as it states but an 
office visit in which you received a shot in our knee. You also say that before it has been a $0 charge on your 
part, excluding the office visit payment. 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 $295 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay $242.59, which is less than the $295 copayment for an arthrocentesis, aspiration 
and/or injection, major joint or bursa. An arthrocentesis, aspiration and/or injection, major joint or bursa falls 
within the Outpatient Surgery and Other Medical 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 an 
arthrocentesis, aspiration and/or injection, major joint or bursa (20610) provided on November 12, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an emergency room (ER) visit provided on 
December 16, 2021. 
 
You asked the Plan to waive the coinsurance for an ER visit. 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 5% 
coinsurance for an in-network emergency room visit. The contract also says that there is a $100 maximum out-
of-pocket per visit. 
 
 You have been asked to pay a total of $50.15, which is 5% coinsurance for an ER visit on December 16, 2021. 
 
Service Code Allowed Amount 5% Coinsurance 
450 $402.66 $20.13 
260 $225.28 $11.26 
352 $254.76 $12.73 
402 $120.63 $6.03 
Total  $50.15 
 
An emergency room 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 coinsurance for an emergency room (ER) visit provided on December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Full Urinary Tract Infection Panel provided to the enrollee 
on October 11, 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 there is a lack of data to suggest that these panels after medical decision making. 
 
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 a review of the medical literature and clinical practice guidelines, including by 
the Infectious Disease Society of America and Healthcare Infection Control Practices Advisory Committee 
(HICPAC), state standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a 
urine culture and susceptibility studies. In addition, there is lack of support for the clinical utility of large 
multiplex PCR urinary tract infection panel tests. The review indicates that the services at issue in this case are 
not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a Full Urinary Tract Infection Panel provided to the enrollee on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Parent's Choice baby diapers you purchased on 
December 22, 2021. 
 
You asked the Plan to pay for the diapers. You say that you use these diapers as a bladder control pad, so they 
should be covered. The Plan denied your request. The Plan says the diapers you purchased are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable. Although Medicare does not cover incontinence 
supplies, your Plan offers a supplemental over-the-counter benefit.  For that reason, the Plan's coverage rules 
apply.  The Plan's contract documents explicitly state that only the following incontinence supplies are eligible 
for coverage: A + D ointment, adult briefs, barrier cream, bladder control pads, disposable underwear, 
flushable wipes, no-rinse body wash, perineal wash, skin protectant ointment, and washcloths with lanolin.  
Regular baby diapers (regardless of how they are used) are not covered under this benefit. While these diapers may be appropriate in this case, neither the Plan nor Medicare offers coverage of these 
items. Therefore, we decided that the Plan does not have to pay for the Parent's Choice baby diapers you 
purchased on December 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a magnetic resonance imaging (MRI) of 
the lumbar spine provided on November 17, 2021. 
 
You asked the Plan to reduce the copayment for an MRI. You say that the claim was billed wrong and should 
be billed as a freestanding diagnostic imaging center not an outpatient hospital. You also say you should not 
owe the $209.92 copayment. 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 $250 
copayment for in-network diagnostic radiology services, including MRIs, in other facilities such as an 
outpatient hospital.  The record shows this claim was approved, and you have a cost sharing amount. The record also shows that the 
MRI was performed at an outpatient hospital. You have been asked to pay the allowed amount of $209.92, 
which is less than the $250 copayment for an MRI. An MRI falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and 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 reduce the copayment for a 
magnetic resonance imaging (MRI) of the lumbar spine provided on November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory testing provided on November 1, 
2021. 
 
You asked the Plan to waive the copayment for lab tests. You say that this was part of your annual physical 
exam and you have not been charged for this in the past. The Plan denied your request. The Plan says the 
copayment amount 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 $20 copayment for lab tests, and that a separate 
copayment applies to lab tests even if they are performed during an annual physical exam.  
 
You have been asked to pay $20 copayment for lab tests. Lab tests fall within the Outpatient Diagnostic Tests 
and Therapeutic Services and 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 copayment 
for laboratory testing provided on November 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery services provided by an ambulatory 
surgical center (ASC) on November 8, 2021. 
 
You asked the Plan to pay for the ASC services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you did not bill with an appropriate surgical procedure 
code in order to be paid as an ASC. 
 
The Plan must follow Medicare rules. Medicare rules say that under the Ambulatory Surgical Center (ASC) 
payment system, Medicare makes facility payments to ASCs only for the specific ASC covered surgical 
procedures on the ASC list of covered surgical procedures.  You did not bill this claim with a specific ASC-
covered surgical procedure code.  Rather, you just billed with a revenue code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ASC services have not been met. Therefore, we decided that the Plan does not have to pay for 
outpatient surgery services provided by an ambulatory surgical center (ASC) on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ophthalmological services provided on November 9, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Ophthalmological services. 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 it was determined 
these services were 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 Ophthalmological 
services provided on November 9, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve an upper respiratory infection panel provided to the enrollee on 
November 10, 2021. 
 
You asked the Plan to pre-approve the testing. You say that this should be paid for. The Plan denied your 
request. The Plan says that this does not meet the requirements for approval, as the panel performed had more 
than five pathogens on it. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the testing. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee presented to the clinic for COVID-19 testing. She had associated diagnoses of headache, 
wheezing, pain in throat, myalgia, shortness of breath, nasal congestion, cough and fever. She was 
recommended to continue current antibiotics. Strep testing was negative. Rapid Flu and COVID-19 testing was 
negative. The review has determined that the services at issue in this case were medically reasonable and 
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 the testing have been met. Therefore, we decided that the Plan has to pre-
approve an upper respiratory infection panel provided to the enrollee on November 10, 2021.  
 
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 waive the copayment and patient responsibility for chiropractic 
services rendered from February 10, 2021, to December 17, 2021. 
 
You asked the Plan to waive the copayment and patient responsibility for the chiropractic services. You say 
that you feel the Plan is not paying their share. The Plan denied your request. The Plan says the cost sharing 
was applied 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 $20 
copay for each Medicare-covered visit. The contract also says that the Plan only covers manual manipulation 
of the spine to correct subluxation. The muscle tests and trigger point therapy do not fall under this category 
and, therefore, are not covered services. 
 
You have been asked to pay a $744 for the chiropractic services. This includes a $20 copay for each of the 
eleven dates of services, plus the payment for the uncovered services. The chiropractic services fall within the 
Chiropractic 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 and patient 
responsibility for chiropractic services rendered from February 10, 2021, to December 17, 2021.