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

 
We decided that the Plan does not have to pre-approve use of Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the records 
do not include bloodwork within the last month with ferritin and/or transferrin saturation results. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Feraheme. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested use of Feraheme. Our physician reviewer found 
the enrollee has anemia, but records do not document iron deficiency to meet criteria. The requested use of 
Feraheme is not supported by one of the major drug compendia or by clinical research appearing in a 
Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Feraheme.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
March 2, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you should not have this copayment. 
The Plan denied your request. The Plan says the copayment applied was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $120 copayment for Emergency care.  
 
The enrollee has been asked to pay a $120 copayment for an (ER) visit. An ER visit falls within the Emergency 
Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room 
(ER) visit provided on March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided to the enrollee on January 
11, 2022 and January 12, 2022. 
 
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 payment for this post-operative visit was included in the payment for the surgical procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99232 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not 
support the use of CPT 99232, due to there being a global period of 10 days with CPT 36565 that was performed within the same practice. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care provided to the enrollee on January 11, 2022 and January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foam dressing wound cover (A6212) provided on March 24, 
2022. 
 
You asked the Plan to pay for foam dressing wound cover. You say that you have provided records to support 
the services at issue. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 CPT code A6212 has a status indicator of P on the Physician Fee Schedule. This means that CPT 
code A6212 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of foam dressing wound cover have not been met. Therefore, we decided that the Plan does not have to pay for 
foam dressing wound cover (A6212) provided on March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the miscellaneous durable medical equipment, ostomy 
supplies (E1399) purchased April 19, 2022. 
 
You asked the Plan to pay for the ostomy supplies. You say that you are requesting reconsideration because 
you have been getting the supplies for 3 or 4 years and the Plan would always pay but the supplier was out of 
supplies at the time and it was an emergency. The Plan denied your request. The Plan says if you go to a 
provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services 
you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the miscellaneous durable medical 
equipment, ostomy supplies (E1399) purchased April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this was a medically appropriate visit. The Plan 
denied your request. The Plan says the services were billed, rendered and referred by non-participating 
providers. The Plan also says that they have 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 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 an office visit provided on March 22, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electroencephalogram (EEG) provided to the enrollee 
from March 19, 2021, to March 22, 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 was an incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95720 is "Electroencephalogram (EEG), continuous 
recording, physician or other qualified health care professional review of recorded events, analysis of spike and 
seizure detection, each increment of greater than 12 hours, up to 26 hours of EEG recording, interpretation and 
report after each 24-hour period; with video (VEEG)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation includes an 
EEG interpretation and report. In this case, the procedure was billed without an appropriate modifier. The procedure was performed while inpatient hospital status, in which payment for the technical component would 
be reimbursed to the facility. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for an electroencephalogram (EEG) provided to the enrollee from March 19, 2021, to March 22, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0220, D0120, D1110, D1206) provided 
from January 24, 2020, to November 24, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges and did not know there was a deadline to submit claims. The Plan denied your request. The 
Plan says the services denied correctly as the claims were not submitted within the 1-year deadline. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the dental services was not filed until March 2nd, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for dental services (D0220, D0120, D1110, D1206) provided from 
January 24, 2020, to November 24, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided on March 11, 2022, to March 24, 2022. 
 
You asked the Plan to waive the copayment for SNF stay. You say that you should not have to pay this 
copayment, as you were not consulted on going to this facility. The Plan denied your request. The Plan says the 
copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment per day for days 1-20 for skilled nursing facility (SNF) care.  
 
You have been asked to pay a total of $260 for the SNF stay ($20/day x 13 days = $260). A SNF stay falls 
within the Skilled Nursing Facility (SNF) 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 
copayment for a skilled nursing facility (SNF) stay provided on March 11, 2022, to March 24, 2022.  Your complaint about not giving consent to go to the facility is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transthoracic echocardiogram (TTE) with 
doppler provided on March 16, 2022. 
 
You asked the Plan to waive the copayment for the TTE with doppler. You say that you do not know why 
insurance did not pay any part of the claim. 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 $170 
copayment for radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay $142.35, which is less than the $170 copayment for the TTE with doppler. The 
TTE with doppler falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. Please note that the Plan covers any amount allowed over the copayment amount. Since the total 
allowed charge in this case was less than the copayment amount per the EOC, you are only responsible for the lesser 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 transthoracic echocardiogram (TTE) with 
doppler provided on March 16, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tempus Gene Panel provided to the enrollee on January 24, 2022. 
 
You asked the Plan to pay for the services. You say that this will be useful for patients at initial diagnosis, or 
for a patient with refractory disease. The Plan denied your request. The Plan says that this is not Food and Drug 
Administration (FDA) approved, or cleared as a companion in vitro diagnostic. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are 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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that per the National Comprehensive Cancer Network (NCCN) guidelines, next-generation sequencing 
(NGS) can be considered after an initial determination of histology has been made in patients with cancers of 
unknown primary (CUP). Depending on the study, mutations with potential therapeutic relevance have been 
identified in 30% to 85% of CUP patients. This is a standard of care and not investigational. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the Tempus Gene Panel provided to the enrollee on January 24, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgery (15574, 99070) provided October 21, 
2021. 
 
You asked the Plan to pay for the outpatient surgery. You say that the doctor's office told you the insurance 
would only cover the material for the bone graft and you would be responsible for everything else. You should 
be able to get what is normally paid. The Plan denied your request. The Plan says if you go to a provider who is 
not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
outpatient surgery (15574, 99070) provided October 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided on January 20, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the surgical services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not 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 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 surgical services provided on January 20, 2022 by 
an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from October 
21, 2021, to October 28, 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 the provider did not follow Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report home health services with a RAP in a timely manner. 
 
 
 
 
 
 The RAP was submitted on October 28, 2021, which is more than five days after the start of care. 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 home health services provided to the enrollee from October 21, 
2021, to October 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
February 1, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the provision of F1CDx to the enrollee meets 
the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 
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 next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been 
met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test 
(0037U) provided February 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on February 1, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the PT services. The Plan denied your request. The Plan says these services were 
rendered by an OON provider. The Plan also says these services were not authorized and are not payable by the 
Plan. 
 
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 the physical therapy (PT) services provided on 
February 1, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for out-of-network (OON) laboratory services 
provided on October 25, 2021. 
 
You asked the Plan to waive the deductible for the OON lab services. You say that it is not your fault that the 
labs were sent to an out-of-network facility. The Plan denied your request. The Plan says the correct amount 
was applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible which applies to certain items and services.  
 
The lab services fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the OON lab services were received on October 25, 2021. Therefore, we decided that the 
Plan does not have to waive the deductible for out-of-network (OON) laboratory services provided on October 
25, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a transthoracic echocardiogram (TTE) with 
doppler provided on February 21, 2022. 
 
You asked the Plan to waive the deductible for the TTE with doppler. You say that your copayment should 
only be $140 for radiological diagnostic services. The Plan denied your request. The Plan says the correct 
amount was applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1,000 deductible which applies to certain items and services.  
 
The TTE with doppler falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,000 
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the TTE with doppler was received on February 21, 2022. Therefore, we decided that the 
Plan does not have to waive the deductible for a transthoracic echocardiogram (TTE) with doppler provided on 
February 21, 2022.