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

 
We decided that the Plan has to pay for the FANCC genetic testing rendered on February 2, 2022. 
 
You asked the Plan to pay for these services. You say that the services are not covered. The Plan denied your 
request. The Plan says that [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."] 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan references Local Coverage Article (LCA) A53628 in their 
determination; which is not binding for the services at issue and is superseded by National Coverage 
Determination (NCD) 90.2, which allows for coverage of this testing. Therefore, we decided that the Plan has 
to pay for the FANCC genetic testing rendered on February 2, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on March 3, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
this transport was medically necessary, and you would like this claim to be reviewed and reprocessed for 
payment. The Plan denied your request. The Plan says this request is not medically necessary because the 
criteria requirements outlined in Medicare rules for this service are not met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the non-emergency ambulance 
transportation and ground mileage. Our reviewer says that the documentation does not support that the 
ambulance transport was medically reasonable and necessary for the enrollee. Our physician reviewer found 
the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, 
private car, or other type of vehicle) were contraindicated for this enrollee on March 3, 2022. Our reviewer 
found that the documentation does not support that the enrollee needed the expertise, services and lifesaving 
and life-sustaining equipment that only a fully equipped ambulance could provide for safe transport. 
 
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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on March 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing or skilled therapy needs. The enrollee is functioning at a level commiserate with her injury and 
baseline medical conditions. The enrollees care needs, custodial and intermittent, can, as a practical matter, be 
provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne testing provided on February 5, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing is 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 the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation.  
 
We looked at the file and Medicare rules. The records in this case include the test results and pathology results. 
The records do not include the enrollees treatment plan from their provider. The records do not show that the 
enrollee has decided to seek further cancer treatment. Based on this information, we decided that the Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne testing provided on February 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gym membership from May 1, 2021, to December 31, 
2021. 
 
You asked the Plan to pay for the gym membership. You say that you would like to appeal this denial because 
you feel it is unfair, and something you are entitled to. The Plan denied your request. The Plan says the request 
you submitted was more than 60 days after the end of your plan year. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when the requests are submitted no later than 60 days after the end of the Plan year. 
 
The Plans rules for coverage of gym benefits have not been met because this case was not received by the Plan 
until March 21, 2022, which is more than 60 days after the end of the 2021 plan year. Therefore, we decided 
that the Plan does not have to pay for the gym membership from May 1, 2021, to December 31, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided from August 19, 2021, to August 
31, 2021. 
 
You asked the Plan to pay for the inpatient care services. You say that this is a Value-Based Insurance Design 
(VBID) hospice claim. You also say that the services should be paid. The Plan denied your request. The Plan 
says the claim processed correctly. 
 
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 the inpatient care provided from August 19, 2021, to August 
31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on October 20, 2021. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says these services are not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management 
(face-to-face) service is provided on the same day to the same patient by the same physician or more than one 
physician in the same specialty in the same group, only one evaluation and management service may be 
reported.  
 
We looked at the file and Medicare rules. In this case, two E/M services (99214) were billed on the same date 
of service by the same group practice. The Plan paid for one of these services. This means that the requested 
E/M visit is not payable. Based on this information, we decided that Medicare rules for coverage of the visit 
have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99214) 
provided on October 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance cholangiopancreatography 
(MRCP) (S8037). 
 
You asked the Plan to pre-approve an MRCP. The Plan denied your request. The Plan says this request cannot 
be approved because the records did not include a detailed history that shows this study is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only 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 pre-approve an MRCP. Our reviewer says that an 
MRCP is not reasonable and necessary. Our physician reviewer found there was no abdominal exam provided, 
no liver function tests provided, and no ultrasound provided. The available records do not support 
contraindication to ultrasound performance as the next appropriate imaging study. Our reviewer found that the 
MRCP as requested is both premature and inappropriate based on available records. Our physician reviewer 
also found that the medical necessity for the enrollee at this time for an MRCP is not demonstrated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRCP have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance cholangiopancreatography (MRCP) (S8037).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gauze, Foam dressing and conforming bandage provided on 
February 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for gauze, Foam dressing and conforming bandage. You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-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 gauze, Foam dressing and conforming bandage 
provided on February 28, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 14, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 laboratory services provided on March 14, 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 laboratory services related to end-stage renal disease 
(ESRD) provided on February 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the services were medically 
necessary. 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 
February 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the breast prosthesis provided on May 11, 
2022. 
 
You asked the Plan to waive the cost share for the breast prosthesis. You say that that you should not be 
financially responsible for this item. That you did not want the breast forms items, just the bras. 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 20% 
coinsurance for prosthetic devices.  
 
You have been asked to pay a $59 coinsurance for the prosthetic device ($295 the allowed amount x 20% = 
$59). Breast prosthesis falls within the Prosthetic Devices and Related 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 cost share for the breast prosthesis provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to issue reimbursement for the fitness class (A9270) provided on September 3, 
2021. 
 
You asked the Plan to issue reimbursement 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 this fitness class is not covered 
under your contractual policy. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
We reviewed the case file and the Plans rules. Based on this information, we decided that the Plans rules for 
coverage of this fitness class have been met. Specifically, the documentation in this case file shows that you 
attended a Strength and Balance class on this day. The Plan has stated that a denial was issued as this is a non-
covered fitness class. The Plan contract states that the benefit includes covered instructional fitness classes. 
However, the Plans contract provides examples of such classes but does not state all fitness classes covered. 
This type of class is instructional and does involve fitness. Therefore, we decided that the Plan has to issue 
reimbursement for the fitness class (A9270) provided on September 3, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says an intensive rehabilitation program is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a consultation 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 a consultation to be provided by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 23, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you have no direct patient encounter, and 
therefore no means of knowing if a preauthorization is required prior to you processing the specimen. The Plan 
denied your request. The Plan says services from non-participating providers are not covered under open access 
unless preauthorized. 
 
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 laboratory services provided on February 23, 
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 acupuncture provided on March 25, 2022, to April 4, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the acupuncture. You say that you were previously advised of your acupuncture 
benefits and that you had coverage. 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 
acupuncture. We found no exception that would require the Plan to pay for the acupuncture. The records 
provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that 
the Plan does not have to pay for acupuncture provided on March 25, 2022, to April 4, 2022, by an out-of-
network (OON) provider.