Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 29, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee was unaware that an authorization was 
needed to see the provider. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved 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 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 December 29, 2021, by 
an OON provider.
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 from January 1, 2022, to January 26, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that the staff told you your stay was 
approved but you were never told about being charged extra. You also say you cannot afford to pay that 
amount. 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 $0 
copayment for days 1-20 for a skilled nursing facility stay. The contract also says that you must pay a $184 
copayment per day for days 21-100. 
 The record shows this claim was approved, and you have a cost sharing amount. You are not being charged for 
the first 20 days you were in SNF from January 1, 2022, to January 26, 2022. Therefore, you have been asked 
to pay a total of $920, which is $184 copayment per day for the remaining five days of your SNF stay ($184 
copayment x 5 days = $920). 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 from January 
1, 2022, to January 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist consultation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist consultation. You say that you are requesting coverage for a 
consultation with a national abdominal wall repair authority provider about what might now be possible to 
repair through further surgery, and/or how to better manage the injury you have. The Plan denied your request. 
The Plan says they will not refer you to a non-network provider for this service, and you will be offered a 
second opinion with Plan abdominal wall reconstruction surgeon. 
 
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 specialist consultation to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on February 2, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the outpatient services. You say that it was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says the rendering provider is an OON provider and there was 
no referral from an in-network provider or an approved authorization. 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 outpatient services provided on February 2, 
2022, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 9, 
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 an appropriate modifier was not billed with this code edit. 
 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 imaging services provided to the enrollee on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis (81455) provided 
December 23, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that \testing was requested directly from the 
treating physician who makes the professional determination of diagnosis and medical necessity to successfully 
treat the patient. The Plan denied your request. The Plan says Targeted genomic sequence analysis panel, code 
81455, is non-covered by Medicare. 
 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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for targeted genomic sequence analysis (81455) provided December 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 6, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider ordered the testing to 
be done out of medically necessity. The Plan denied your request. The Plan says the rendering and referring 
providers are both OON providers and there was no approved authorization. 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 6, 
2021, by an OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
October 28, 2021. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the laboratory 
technician advised your physician to send you to the emergency room because of an inaccurate reading. The 
Plan denied your request. The Plan says the proper copayment was applied. 
 
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 $90 
copayment for each emergency room visit.  
 
  You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency 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 an 
emergency room visit provided on October 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical arthroscopy services provided to the enrollee on July 
8, 2020. 
 
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 denied codes remain not supported. 
 
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 the denied codes is: 
 
Current Procedural Terminology (CPT) 29824 -arthroscopy, shoulder, surgical; distal claviculectomy including 
distal articular surface (Mumford procedure) 
 
Current Procedural Terminology (CPT) 29999 -unlisted procedure, arthroscopy 
 
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 in terms of CPT 29824, the operative report does not include enough documentation to 
confirm a distal claviculectomy and distal articular surface was performed. Per operative report "Next, a high-
speed cutting bur was inserted through the anterior portal to complete a coplaning of the distal clavicle". In 
terms of CPT 29999, the provider is reporting subcoracoid decompression as an unlisted procedure. Coracoid 
decompression is included in CPT  29826 when acromioplasty is performed; otherwise, it is considered 
debridement under CPT 29822 or CPT 29823. In this case, this procedure is a debridement and is inclusive to 
CPT 29823.  
 
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 surgical arthroscopy services provided to the enrollee on July 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for epidural injection with imaging guidance 
provided on August 23, 2021 and November 8, 2021. 
 
You asked the Plan to waive the copayment for epidural injection with imaging guidance. You say that you did 
not receive services in a hospital so you should not be charged for outpatient hospital services. The Plan denied 
your request. The Plan says copayment is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $295 
copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, 
including but not limited to hospital or other facility charges and physician or surgical charges.   
You have been asked to pay $295 copayment for epidural injection with imaging guidance. The epidural 
injection with imaging guidance falls within the Outpatient Surgery and Other Medical 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 epidural injection with imaging guidance provided on August 23, 2021 and 
November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory testing to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve laboratory testing. You say that you consider this service to be medically 
necessary. The Plan denied your request. The Plan says they are denying the non-participating laboratory 
because the Plan's participating laboratory can provide similar or identical testing, and the test itself is not 
being denied, as long as it is provided by a participating laboratory. 
 
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 
laboratory testing to be provided 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 portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. 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 follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) National Coverage Determinations Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 
stipulates that ventilators (E0465, E0466, and E0467) are covered when specific criteria are met. 
 
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 portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You have moderate to severe chronic obstructive pulmonary disease (COPD). The partial pressure 
of carbon dioxide (PaCO2) was mildly elevated when acutely ill in 2021, in a pattern consistent with acute 
hypercarbia. There is no documentation of carbon dioxide retention when stable as an outpatient. Bilevel 
positive airway pressure (Bipap) with average volume-assured pressure support (AVAPS) mode has not been 
tried at home.  Medicare does not pay for a home ventilator when used as bipap. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis (81455) provided 
November 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the testing was requested directly from the 
treating physician who makes the professional determination of diagnosis and medical necessity to successfully 
treat the enrollee. The Plan denied your request. The Plan says Genetic testing procedures submitted with code 
81455 is non-covered by Medicare as they are unlikely to impact therapeutic decision-making in the clinical 
management of the patient and will be denied automatically as 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for targeted genomic sequence analysis (81455) provided November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an Office visit on January 13, 2022. 
 
You asked the Plan to waive the deductible for an Office visit. You say that you would like for your insurance 
plan to cover the cost of the visit beyond the $10 that has already been paid. The Plan denied your request. The 
Plan says the total cost share of $224.64 was applied 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 $500 
deductible for an Office visit. The provider billed the plan in the amount of $355.00 and the allowed amount is 
$224.64. Since the member had not reached their deductible, the full allowed amount of $224.64 was applied 
correctly as member liability. 
 
You have been asked to pay a $500 deductible for an Office visit. An Office visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the deductible for an Office visit on January 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on September 
17, 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 no emergency or urgency, and no prior authorization on file. 
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. 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 patient. According to the ambulance 
documentation, the patient had no apparent injury or illness and was transported from the emergency 
department to a private residence. The documentation does not support that the patient needed the expertise, 
services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe 
transport on 9/17/21. There were no abnormal physical examination findings and vital signs were stable. The 
documentation does not support that the ambulance transport was medically reasonable and necessary for the 
patient on 9/17/21.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services provided to the enrollee on September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Hospital outpatient clinic visit provided on February 3, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Hospital outpatient clinic visit. 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 were 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 Hospital outpatient clinic visit provided on 
February 3, 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 the physician services provided on January 29, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the physician services. You say that it is the facilities responsibility to obtain 
prior authorization and it was medically necessary to treat the enrollee. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no approved 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 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 physician services provided on January 29, 
2021, by an OON provider.