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

 
We decided that the Plan does not have to pay for the laboratory services provided on October 25, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee's ordering physician us 
responsible for obtaining authorization. The Plan denied your request. The Plan says the rendering provider is 
an out-of-network provider and there was no referral or authorization from an in-network provider. Also, the 
service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 25, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig (A9282). 
 
You asked the Plan to pre-approve a wig. You say that this is necessary as a result of your medical condition. 
The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig (A9282).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 25, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that you were not aware of the requirement to obtain 
prior authorization. You said these services were provided in good faith and should be paid. The Plan denied 
your request. The Plan says neither your lab nor the referring provider is a network provider with the Plan.  The 
Plan says that unauthorized, non-plan care is not covered. 
 
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 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 lab services provided on October 25, 2021, by an out-of-network 
(OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
September 28, 2021 to October 1, 2021 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 
provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment per day for days 1-5 of Inpatient hospital care.  
 
 You have been asked to pay a $842 copayment for 3 days of inpatient hospital care. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an inpatient hospital stay provided from September 28, 2021 to October 1, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation for use and/or fitting of a voice prosthetic 
device to supplement oral speech (92597) and a tracheo-esophageal voice prosthesis (L8509) provided on 
September 17, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for evaluation for use and/or fitting of a voice prosthetic device to supplement oral 
speech and a tracheo-esophageal voice prosthesis. You say that you are not sure how much more proof the Plan 
needs to authorize the payment of this procedure. The Plan denied your request. The Plan says that the 
member's primary care provider (PCP) is a part of an independent practice association (IPA) or medical group 
(PMG). The Plan also says that page 42 of the Plan's 2021 Evidence of Coverage (EOC) states that if you 
choose a PCP that is part of an IPA or a PMG, the specialists, ancillary providers, and hospital available to you 
may be limited to only those contracted with the PCP's IPA or PMG. The plan also says that for certain services 
provided ty specialists, either your PCP or specialist will need to get prior approval from us, and this is called getting "prior authorization." The Plan also says that there is no information found that the member was 
approved to receive services with the rendering provider on September 17, 2021. 
 
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 the evaluation for use and/or fitting of a voice 
prosthetic device to supplement oral speech (92597) and a tracheo-esophageal voice prosthesis (L8509) 
provided on September 17, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair (PWC) electronic connection 
(E2310). 
 
You asked the Plan to pre-approve the PWC electronic connection. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item 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 the PWC electronic connection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the patient's upper extremity function with independence in eating supports that 
the patient can control any power options through their own switches. 
 
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 PWC electronic connection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the power wheelchair (PWC) electronic connection (E2310).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device 
(Vertiflex). 
 
You asked the Plan to pre-approve Vertiflex. You say that the enrollee has failed conservative approaches and 
is a good candidate for Vertiflex. The Plan denied your request. The Plan says the denial of authorization for 
this service is correct, because this procedure is experimental/investigational. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/investigational procedure. 
 
 
 
 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
provided on September 27, 2021. 
 
You asked the Plan to pay for ambulance service, basic life support, emergency transport. The Plan denied your 
request. The Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. 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 ambulance service, basic life support, 
emergency transport. Our reviewer says that the ambulance transport was not medically reasonable and 
necessary. Our physician reviewer found based on the medical records provided there is no documentation 
that the enrollees presenting symptoms meet prudent layperson criteria for emergency care. Although the 
records document weakness and confusion and that the enrollee initially was not responding to commands, he was later responding and answering questions. The records do not document any hemodynamic or vital sign 
instability, injury, agitation or combativeness. There is no documentation 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 September 27, 2021. There is no documentation that the enrollee needed the expertise, services and 
lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on 
September 27, 2021. There is no documentation that the ambulance transport on September 27, 2021 was 
medically reasonable and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance service, basic life support, emergency transport have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency 
transport provided on September 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on November 10, 
2021. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you thought that this would be a 
preventative service. The Plan denied your request. The Plan says the claims were processed correctly and you 
are being charged the correct 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 $350 
copayment for outpatient surgery, including services provided at ambulatory surgical centers.  
 
The medical records show that you received a diagnostic colonoscopy at an ambulatory surgical center on November 10, 2021. Therefore, you are responsible to pay the $350 copayment.  
 
You have been asked to pay a $350 copayment for a colonoscopy. A colonoscopy 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 a colonoscopy provided on November 10, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services, and related medical care 
provided on August 29, 2019. 
 
You asked the Plan to pay for the emergency room services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been 
filed timely. 
 
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 emergency room services was not filed until March 11, 2021. 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 the emergency room services, and related medical care provided 
on August 29, 2019.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is in pain. The Plan denied 
your request. The Plan says that a plan to use a computed tomography (CT) scan was not described. 
 
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. 
 
We looked at the file and the rules. The case file does not show that the Plan did not receive medical records. 
The file does not show that records were requested and not received. The Plan has not provided the medical 
records that were used to deny the services. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request.  Therefore, we decided that the Plan 
has to pre-approve epidural steroid injections.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 4, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that you were not aware of the requirement for prior 
authorization.  You said that these services were provided in good faith and should be paid. The Plan denied 
your request. The Plan says neither your lab nor the referring provider is a network provider with the Plan.  The 
Plan says that unauthorized, non-plan care is not covered. 
 
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 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 lab services provided on November 4, 2021 by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth psychotherapy services (90832) provided on June 
2 to July 7, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for telehealth psychotherapy services. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-
network care 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The contract provides for telehealth services only when provided 
by network providers. 
 
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 telehealth psychotherapy services (90832) 
provided on June 2 to July 7, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on December 3, 2021. 
 
You asked the Plan to waive the copayment for the x-ray. You say that the services should be covered. The 
Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $75 copayment for an x-ray. X-rays fall 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 
an x-ray provided on December 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for an x-ray of each hand provided on 
October 21, 2021. 
 
You asked the Plan to reduce the copayments for an x-ray. You say that you had x-rays of both of your hands. 
You also say you had one service and they charged you twice. 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 $30 
copayment for each x-ray service.  
 
The records show you had two separate x-rays (codes 73130LT and 73130RT) even though they were 
performed at the same time. You have been asked to pay a total of $60, which is a $30 copayment for an x-ray of each hand. An x-ray 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 reduce the copayments for an x-ray of each hand provided 
on October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed 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 July 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is not medically necessary. 
 
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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital with 
COVID infection and irregular heartbeat (atrial fibrillation). You received oral medications and had stable vital 
signs. You received physical and occupational therapy in the hospital and are walking 120 feet with minimal 
assistance. You need varied assistance with activities of daily living. You have no skilled nursing needs. You 
have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do not 
require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.