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

 
We decided that the Plan does not have to pay for the telehealth services provided on July 9, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says telehealth services are only covered when 
provided by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that if you choose to get services by telehealth, you must use a network provider who offers the 
service by telehealth. 
 
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 telehealth services provided on July 9, 2021, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed. 
 
You asked the Plan to pre-approve a hospital bed. You say that the item is 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 a fixed height hospital bed (E0250, E0251, E0290, 
E0291, and E0328) is covered if specific criteria are met. 
 
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 hospital bed. Our reviewer says that 
the item is not medically necessary. Our physician reviewer found based on the medical records provided there 
is no documentation that supports that a hospital bed is medically necessary for you as defined by Medicare 
criteria in the Local Coverage Determination (LCD): Hospital Beds And Accessories - L33820. Records do not 
document that you have a medical condition which requires positioning of the body in ways not feasible with an ordinary bed or requires positioning of the body in ways not feasible with an ordinary bed in order to 
alleviate pain or requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration or requires traction equipment 
which can only be attached to a hospital bed. 
 
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 hospital bed have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical exam provided on November 15, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the medical exam. You say that it is the facilities responsibility to get prior 
authorization and the claim should be reprocessed for payment. The Plan denied your request. The Plan says 
the rendering provider is an out-of-network 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 a medical exam provided on November 15, 2021, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy service (90832) rendered by the out-of-
network (OON) provider on September 22, 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 psychotherapy service (90832) rendered by the out-of-network (OON) provider on 
September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the incision and drainage of an abscess 
(10060) and the office visit (99203) provided on December 10, 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 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 $45 
copayment for each Medicare-covered visit for medically necessary foot care.  
 
You have been asked to pay a $45 copayment for the Medicare-covered podiatry visit 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 incision and drainage of an abscess (10060) 
and the office visit (99203) provided on December 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a zoledronic acid injection. 
 
You asked the Plan to pre-approve a zoledronic acid injection. 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 bisphosphonate injections (administered 
intravenously [IV]) will be considered medically reasonable and necessary when administered under specific 
circumstances. 
 
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 zoledronic acid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the provided 
documentation did not include evidence of the enrollee having tried and failed or having a contraindication to 
oral bisphosphonate to justify this request. Therefore, the criteria for zoledronic acid injection are not met. 
 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 zoledronic acid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a zoledronic acid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on November 30, 2021. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the refraction 
service was not part of a routine eye exam. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to 
pay for an eye refraction provided on November 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that the orthopedic footwear is medically necessary. 
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 (L3000).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory work provided by a network 
physician on June 17, 2021. 
 
You asked the Plan to waive the copayment for the laboratory work. You say that the prostate specific antigen 
(PSA) test should be covered once a year with no out-of-pocket costs. The Plan denied your request. The Plan 
says you have been asked to pay 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 $5 
copayment for diagnostic laboratory services and diagnostic procedures and tests (per day, per facility). This 
excludes basic and advanced diagnostic imaging services.  
 
 
 You have been asked to pay a $5 copayment for the laboratory work. The laboratory work falls within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. The record shows the PSA 
was ordered due to increasing urinary symptoms which makes the test diagnostic in nature. 
 
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 work provided by a network physician on June 
17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on October 29, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says there is no information provided that the 
results of testing were used by the treating physician for management of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that Guardant360 testing may be covered when specific 
criteria are met. 
 
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 Guardant360 testing. Our reviewer says 
that the documentation does not support that the enrollee is either untreated or not responding to treatment. Our 
physician reviewer found the documentation does not clearly indicate that the enrollee has decided to seek 
further treatment. 
 
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 Guardant360 testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guardant360 testing provided on October 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement of the copayment for the 
esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple (43239) provided on 
September 27, 2021. 
 
You asked the Plan to issue reimbursement. 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 $200 
copayment for Medicare-covered outpatient hospital facility visits.  
 
 You have been asked to pay a $200 copayment for the Medicare-covered outpatient hospital facility visit for 
the outpatient surgery 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 issue reimbursement of the copayment for the 
esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple (43239) provided on 
September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 17, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 laboratory 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 the laboratory services provided on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pharmacogenetic testing provided to the enrollee 
on June 7, 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 Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 molecular pharmacogenetic testing provided to the enrollee on June 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on 
November 8, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you do not understand why 
you were charged a copayment for a procedure to diagnose cancer. The Plan denied your request. The Plan 
says the proper copayment was applied for the service that was rendered. 
 
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 $150 
copayment for each Medicare-covered outpatient surgery or procedure at an outpatient hospital facility or 
ambulatory surgical center.  
 
  You have been asked to pay a $150 copayment for the outpatient surgery. The outpatient surgery 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 an outpatient surgery provided 
on November 8, 2021.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for a transthoracic echocardiography, with contrast, or 
without contrast followed by with contrast, real-time with image documentation (2d), (C8930) provided on 
October 27, 2021.  
We decided that the Plan does not have to waive all of the copayment for a transthoracic echocardiography, 
with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), (C8930) 
provided on October 27, 2021.  
 
You asked the Plan to reduce the copayment for a transthoracic echocardiography, with contrast, or without 
contrast followed by with contrast, real-time with image documentation (2d), (C8930) provided on October 27, 
2021. You say that you have never had to pay the $275 in previous years of this test. You also say you spoke 
with a Plan rep on December 13, 2021, and was told that this bill was cleared, and you only owed the $55 
copayment. You also say you still received a bill for $275, and you have spoken with several people between 
the hospital and the doctors office, who ordered this test, with no resolution. The Plan says that you were 
charged the correct cost sharing amount. 
 
We decided that the Plan has to reduce the copayment for a transthoracic echocardiography, with 
contrast, or without contrast followed by with contrast, real-time with image documentation (2d).  
 
The Plan says that you must pay $220, which is less than the $275 copayment for a transthoracic 
echocardiography, with contrast, or without contrast followed by with contrast, real-time with image 
documentation (2d). Based on our contract with the Plan, however, you can only be asked to pay $55 for each 
Medicare-covered standard x-ray and ultrasound. Therefore, we decided that the Plan has to reduce the 
copayment for a transthoracic echocardiography, with contrast, or without contrast followed by with contrast, 
real-time with image documentation (2d) from $220 to $55. 
 
We also decided that the Plan does not have to waive all of the copayment for a transthoracic 
echocardiography, with contrast, or without contrast followed by with contrast, real-time with image 
documentation (2d). 
 
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 $55 
copayment for each Medicare-covered standard x-ray and ultrasound. Therefore, we decided that the Plan does 
not have to waive all of the copayment for a transthoracic echocardiography, with contrast, or without contrast 
followed by with contrast, real-time with image documentation (2d), (C8930) provided on October 27, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on August 11, 2021. 
 
You asked the Plan to pay for foot orthotics. You say that  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 pay for foot orthotics provided on August 11, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 14, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services were medically necessary and were 
provided in good faith. 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 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 October 14, 2021, by 
an out-of-network (OON) provider.