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

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided from February 
27, 2022, to March 2, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that since you had to stay overnight 
at the hospital and wait for surgery it should be treated as inpatient. The Plan denied your request. The Plan 
says the copayment 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). Your contract with the Plan clearly says that you must pay $300 
copayment for outpatient surgery in an outpatient hospital setting.  
 
You have been asked to pay $300 copayment for outpatient surgery. 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 outpatient surgery provided 
from February 27, 2022, to March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on December 9, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on the facility staff to 
verify eligibility and obtain authorization from the enrollee's insurance company. The Plan denied your request. 
The Plan says no prior authorization was obtained. 
 
 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 
domiciliary visit. We found no exception that would require the Plan to pay for the domiciliary visit. The 
records provided for review do not show that the domiciliary visit was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on December 9, 2021, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on February 16, 2022. 
 
You asked the Plan to pay for laboratory services. You say that your insurance card was accepted at the clinic 
so they should have explained this was out-of-network. You say that you do not understand why this was not 
covered and you do not have $1,824. The Plan denied your request. The Plan says that the services were 
received from a non-participating provider. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The claim supports that the laboratory services were provided at a primary care office and the attending 
physician that performed the laboratory services is a contract provider. The file does not show that the Plan 
provided notice that laboratory services would not be covered due to the hospital billing for the services. Under 
Medicare rules, this means laboratory services is considered approved by the Plan. Therefore, we decided that 
the Plan has to pay for laboratory services provided on February 16, 2022.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatments provided on December 27, 
2021, to January 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medication assisted treatments. You say that your treatment program does 
meet the controlled substance registration certification and the services should be covered. The Plan denied 
your request. The Plan says no prior authorization was obtained. 
 
 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 
medication assisted treatments. We found no exception that would require the Plan to pay for the medicated 
assisted treatments. Therefore, we decided that the Plan does not have to pay for the medication assisted 
treatments provided on December 27, 2021, to January 10, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of the intraosseous basivertebral 
nerve for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are not enough studies to show that this procedure improves health outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. The exam does not demonstrate significant functional 
impairment or debilitating pain. There are no objective exam findings provided to corroborate pathology. 
Overall, documentation was/is lacking regarding reasonably detailed and/or evidenced findings supportive of 
the spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent 
pain. Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested Intracept basivertebral nerve ablation at L3 and L4 vertebral bodies, in this case, is 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 pre-approve thermal destruction of the intraosseous basivertebral nerve for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on January 
21, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that your wife was never given 
the opportunity to drive you so it should be covered. The Plan denied your request. The Plan says the 
copayment 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). Your contract with the Plan clearly says that you must pay $250 
copayment for each one-way Medicare- covered ground trip.  
 
You have been asked to pay $249.35 which is less than the standard $250 copayment for ambulance transport. 
Ambulance transport falls within the Ambulance Services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for ambulance transport provided on January 21, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 27, 2021. 
 
You asked the Plan to pay for laboratory services. You say that the Waiver of Liability is attached, and the 
claim should be processed toward payment. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
February 9, 2022. 
 
You asked the Plan to pay for the dental 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 allowable benefit for this service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the service provided was exhausted on date of service August 13, 2021. The Plan 
contract says that a comprehensive oral evaluation is covered once every three plan years. You previously 
received this service on August 13, 2021; which was paid for by the Plan. Therefore, the benefit for this service 
has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation (D0150) provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for cream for phototherapy provided on 
February 14, 2022. 
 
You asked the Plan to waive the coinsurance for cream for phototherapy. You say that the cream was necessary 
so it should be covered. The Plan denied your request. The Plan says the coinsurance 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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for all drugs covered under Original Medicare.  
 
You have been asked to pay $68.80 which is 20% of the allowed amount for the cream for phototherapy. The 
allowed amount is $344 (20% x $344 = $68.80). The cream for phototherapy falls within the Medicare Part B 
Prescription Drugs 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 cream for 
phototherapy provided on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services 
provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on February 18, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on the facility staff to 
verify eligibility and obtain authorization from the enrollee's insurance company. The Plan denied your request. 
The Plan says no prior authorization was obtained. 
 
 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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the domiciliary visit provided on February 18, 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 comprehensive cardiovascular genetic testing provided 
on December 6, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing was medically necessary with the 
applicable diagnosis codes. The Plan denied your request. The Plan says the services do not meet coverage 
requirements. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The medical records provided do not clearly document the physicians 
intent for the testing to be performed. The testing at issue in this appeal was requested for screening purposes. 
Screening services such as pre-symptomatic genetic tests and services used to detect an undiagnosed disease or 
disease predisposition are not a Medicare benefit and are not covered. Therefore, we decided that the Plan does 
not have to pay for the comprehensive cardiovascular genetic testing provided on December 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of lower extremity arteries or arterial 
bypass grafts (93926). 
 
You asked the Plan to pre-approve a duplex scan of lower extremity arteries or arterial bypass grafts. The Plan 
denied your request. The Plan says a duplex scan of lower extremity arteries or arterial bypass grafts is not 
reasonable or necessary at this time. 
 
The Plan follows Medicare rules. Medicare rules say that a duplex scan is reasonable if the enrollee meets the 
indications for coverage, and does not have any limitations listed in the Medicare rules section above. 
 
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 duplex scan of lower extremity 
arteries or arterial bypass grafts. Our reviewer says that a duplex scan of lower extremity arteries or arterial 
bypass grafts is not medically reasonable or necessary. Our physician reviewer found the enrollee does not 
have an indication that would meet criteria for this test as the pulses were normal, there was no report of 
claudication, abnormal ABI, recent bypass surgery, infection, or other indication described in the 
documentation provided. Our reviewer also found that the limitations found in the documentation that would 
prevent coverage include isolated edema as only symptom and the presence of pain which is not alone an 
indication for advanced testing. 
 
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 duplex scan of lower extremity arteries or arterial bypass grafts have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a duplex scan of lower extremity arteries 
or arterial bypass grafts (93926).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from March 4, 2021, through 
March 6, 2021, at DRG 871. 
 
You asked the Plan to pay for inpatient services. You say that clinical criteria for sepsis were met and the 
discharge summary clearly supports the diagnosis. You say that the diagnosis code is valid and DRG 871 is 
accurate. The Plan denied your request. The Plan says documentation was not found to support diagnosis code 
A41.9. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with principal diagnosis code A41.9, defined as sepsis, 
unspecified. 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 inpatient services. Our reviewer says 
that the documentation does not support principal diagnosis code A41.9. Our physician reviewer found that 
evidence of a dysregulated host response to infection causing life-threatening organ dysfunction was not found 
within the submitted medical records.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from March 4, 2021, through March 6, 2021, at DRG 871.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test purchased on January 12, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 test. You say that the importance of testing was not less 
in January than in February. You also say the intent of the law is to protect members who are at high risk. The 
Plan denied your request. The Plan says the at-home COVID-19 test was not a covered benefit at time of 
purchase. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 test is an OTC item. However, the Plan offers a supplemental benefit for over-the-counter home 
COVID-19 tests purchased after February 1, 2022. These tests were purchased on January 12, 2022, which is 
before this benefit went into effect. Therefore, we decided that the Plan does not have to pay for the at-home 
COVID-19 test purchased on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on April 13, 
2022. 
 
You asked the Plan to waive the copayment for office visit. You say that the doctor you saw couldn't help you 
and you had to reschedule to see someone else. The Plan denied your request. The Plan says the copayment 
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). Your contract with the Plan clearly says that you must pay $35 
copayment for each in-person specialist visit.  
 
You have been asked to pay $35 copayment for office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctor's Office Visits 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 specialist office visit provided on April 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for advanced imaging provided on March 28, 
2022. 
 
You asked the Plan to waive the copayment for advanced imaging. You say that this service should be covered. 
The Plan denied your request. The Plan says the copayment 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). Your contract with the Plan clearly says that you must pay $225 
copayment for advanced imaging services.  
 
You have been asked to pay $225 copayment for advanced imaging. Advanced imaging 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 waive the copayment for advanced imaging provided on March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on July 16, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing was necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says the testing is not a Medicare 
benefit. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The gene panel at issue includes the FANCC gene. Panels of tests 
that include this gene are statutorily excluded. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the gene panel testing 
provided on July 16, 2021.