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

 
We decided that the Plan does not have to pay for a urinalysis (81015) and blood glucose (sugar) level test 
(82947) provided on January 11, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the claim was partially denied, and you would 
like it to be reprocessed. The Plan denied your request. The Plan says non-network providers do not work with 
the Plan and services cannot be authorized unless there is an urgent or emergent need, or if a network provider 
referred the enrollee. The referring provider in this case is also out-of-network. 
 
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 urinalysis (81015) and blood glucose (sugar) 
level test (82947) provided on January 11, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 15, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment based on the medical records. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility (SNF) visit provided on April 5, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a skilled nursing facility (SNF) visit. You say that the patient needed this service, 
and it should be covered. The Plan denied your request. The Plan says there was no preauthorization by a 
primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and 
this was not an emergency. Therefore, the decision is upheld. 
 
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 skilled nursing facility (SNF) visit provided on 
April 5, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapeutic procedures (97530, 97110) 
provided from June 9, 2022 to June 28, 2022. 
 
You asked the Plan to waive the copayment for the therapeutic procedures. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $40 
copayment per visit for Outpatient rehabilitation services.  
 
 
  You have been asked to pay a $240 copayment for 6 visits of therapeutic procedures. This item/service falls 
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 procedures (97530, 97110) provided from June 9, 2022 to June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit, a paring or cutting of benign hyperkeratotic 
lesions, and the trimming of nondystrophic nails provided on August 13, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for a home visit, a paring or cutting of benign hyperkeratotic lesions, and the 
trimming of nondystrophic nails. You say that you informed the front desk secretary to obtain prior 
authorization, yet for some unknown reason, there was a misconception, and the patient was called in for 
treatment, prior to obtaining authorization. The Plan denied your request. The Plan says authorization was not 
obtained prior to the 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 a home visit, a paring or cutting of benign 
hyperkeratotic lesions, and the trimming of nondystrophic nails provided on August 13, 2021, by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a urethral stricture dilation procedure 
(53601) provided on July 12, 2022 
 
You asked the Plan to waive the copayment for urethral dilation. You say that you do not agree with how the 
claims processed. You say you need this procedure four times a year and used to pay a $35 copayment. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $375 
copayment per visit for outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You have been asked to pay a $113.91 copayment for urethral dilation. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category.  
 The Plans allowed amount for this service is $113.91, which is less than the required copayment. You are only 
responsible for this lower amount. 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 a urethral stricture 
dilation procedure (53601) provided on July 12, 2022
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the requested Aranesp is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Retacrit or Procrit first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Aranesp. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has anemia of stage IV chronic renal disease. The requested medication is a new start.  The provided 
records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record 
does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's 
preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home healthcare services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve home healthcare services to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home healthcare services to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE). 
 
You asked the Plan to pre-approve a transthoracic echocardiography (TTE). You say that the requested 
transthoracic echocardiography (TTE) is medically necessary. The Plan denied your request. The Plan says the 
requested transthoracic echocardiography (TTE) is 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 pre-approve a transthoracic echocardiography 
(TTE). Our reviewer says that the requested transthoracic echocardiography (TTE) is not medically necessary. 
Our physician reviewer found the record indicates that the enrollee is able to climb stairs and walk without 
problem. The record provided does not document the presence of any cardiac symptoms at this time. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service at this time. The elements of the coverage criteria are not satisfied. The requested service 
is not recommended. 
 
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 transthoracic echocardiography (TTE) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care rendered by 
the out-of-network (OON) provider from March 1, 2022, through March 14, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the inpatient skilled nursing facility (SNF) care rendered by the out-of-network 
(OON) provider from March 1, 2022, through March 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care rendered by 
the out-of-network (OON) provider from February 1, 2022, through February 28, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the inpatient skilled nursing facility (SNF) care rendered by the out-of-network 
(OON) provider from February 1, 2022, through February 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency ambulance transportation 
(A0427) and non-emergency ambulance transportation (A0428) provided on May 13, 2022, and May 17, 2022. 
 
You asked the Plan to waive the copayments for the ambulance trips. You say that you had to be transported by 
ambulance, and were told there would be no charge for the transportation. The Plan denied your request. The 
Plan says this cost sharing was charged 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 $265 
copayment for Ambulance Services.  
 
 
 
 
 You have been asked to pay $265 copayments for the ambulance trips. This item/service 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 copayments for the emergency 
ambulance transportation (A0427) and non-emergency ambulance transportation (A0428) provided on May 13, 
2022, and May 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care rendered by 
the out-of-network (OON) provider from January 20, 2022, through January 31, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the inpatient skilled nursing facility (SNF) care rendered by the out-of-network 
(OON) provider from January 20, 2022, through January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 the laboratory services related to end-stage renal disease (ESRD) provided on June 7, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on July 05, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 
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 office visit provided on July 05, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on June 22, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for principal care management services. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says this provider is out-of-network with the Plan, 
and authorization was not obtained prior to the 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 principal care management services provided on 
June 22, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for pulmonary rehab on June 13, 2022, to June 
27, 2022. 
 
You asked the Plan to waive the copayment for pulmonary rehab. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $30 
copayment per Medicare-covered pulmonary rehabilitation sessions. Comprehensive programs of pulmonary 
rehabilitation are covered for members who have moderate to very severe chronic obstructive pulmonary 
disease (COPD) and a referral for pulmonary rehabilitation form the doctor treating the chronic respiratory 
disease. There were 4 visits. 4 x $30 = $120. Therefore, results in the total cost sharing amount of $120.  
 
 
 
 
 You have been asked to pay a $30 copayment for each pulmonary rehab. This item/service falls within the 
Pulmonary 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 
pulmonary rehab on June 13, 2022, to June 27, 2022.