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

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on  
February 1, 2022, and February 15, 2022. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on February 1, 2022, 
and February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder test (0012M) provided on October 18, 2021. 
 
You asked the Plan to pay for the CxBladder test. You say that this claim should be reprocessed and approved 
for payment. The Plan denied your request. The Plan says this testing is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that after a review of the literature, non-coverage has 
been reaffirmed for the CxBladder test.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CxBladder test have not been met. Therefore, we decided that the Plan does not have to pay for 
the CxBladder test (0012M) provided on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out of network office visit and 
immunizations provided on September 29, 2021. 
 
You asked the Plan to waive the coinsurance for out of network office visit and immunizations. You say that 
this should be charged at the in-network rate. The Plan denied your request. The Plan says the coinsurance 
applied 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 40% 
coinsurance for immunizations and office visits.  
 
 You have been asked to pay a total of $148.58 which is 40% of the allowed amount for out of network office 
visit and immunizations. The immunizations allowed amount was $38.20 (40% x $38.20 = $15.28). The 
allowed amount for the office visit was $185.05 (40% x $185.05= $74.02) and the allowed amount for the 
preventive medical care was $148.19 (40% x $148.19 = $59.28). Immunizations falls within the Immunizations 
benefit category. The office visits fall 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 coinsurance for out of network office visit and 
immunizations provided on September 29, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for 3D rendering with interpretation postprocessing provided to the 
enrollee on March 16, 2022. 
 
You asked the Plan to pay for the services. You say that you were not aware authorization was needed. The 
Plan denied your request. The Plan says that this was received without prior authorization. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the report of the CT of 3/16/22 shows maximum intensity projection (MIP) 3D post processing was 
done to increase detection of pulmonary nodules and was done on a separate independent workstation and 
reviewed by the radiologist. As such the reason for the 3D post processing was documented and done on a 
separate workstation and then reviewed by the interpreting radiologist. These additional items are documented 
in the report and conform to the requirements issued by Mediare for 3D post processing to be reimbursed. 
 
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 
3D rendering with interpretation postprocessing provided to the enrollee on March 16, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on February 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the eyeglasses. You say that the network providers were more expensive than 
this provider.  You believe you should be reimbursed for these eyeglasses. The Plan denied your request. The 
Plan says eyeglasses you purchase from out-of-network providers are 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 had network providers available 
who could have provided the eyeglasses at issue in this appeal. The Plan did not pre-approve the eyeglasses 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 eyeglasses provided on February 9, 2022, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $288.81 coinsurance for a lumbar-sacral orthosis provided 
on January 10, 2022. 
 
You asked the Plan to waive the $288.81 coinsurance for a lumbar-sacral orthosis provided on January 10, 
2022. You say that you were not advised of your coinsurance responsibility for this item and believed you 
would only be assessed a $10 copayment. The Plan denied your request. The Plan says the coinsurance has 
been 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 20% 
coinsurance for Prosthetic Devices and Related Supplies.  
 
 
 
 
 
 You have been asked to pay a $288.81 coinsurance for a lumbar-sacral orthosis. A lumbar-sacral orthosis falls 
within the Prosthetic Devices and Related Supplies benefit category. The provider billed $4115.00; the Plans 
allowance was $1444.03; $1444.03 x 20%=$288.81. 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 $288.81 
coinsurance for a lumbar-sacral orthosis provided on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on April 26, 
2021. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this copayment should be 
covered. The Plan denied your request. The Plan says the copayment applied 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 $45 
copayment per specialist visit.  
 
You have been asked to pay $45 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctor's 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 copayment for specialist office visit provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on March 7, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this was post op 
appointment so it should be covered. The Plan denied your request. The Plan says the copayment applied 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 $40 
copayment per visit to a specialist.  
 
You have been asked to pay $40 copayment for specialist office visit. Specialist office visits fall 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 copayment for specialist office visit provided on March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PT services provided by a chiropractor on February 2, 
2022. 
 
You asked the Plan to pay for PT services. You say that you would like this service covered. The Plan denied 
your request. The Plan says other services performed by a chiropractor are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for physical therapy (PT) services provided by a chiropractor on February 2, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgical visits provided from 
February 14, 2022, to March 31, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgical visits. You say that if you would have 
known how much the copayments would be you wouldn't have gone there. The Plan denied your request. The 
Plan says the copayments applied are 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 $200 
copayment per visit at an outpatient hospital facility or ambulatory center. 
 
 
 
 
 You have been asked to pay $1,000 (200 x 5 visits) copayment for outpatient surgical visits. Outpatient surgical 
visits fall 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 outpatient 
surgical visits provided from February 14, 2022, to March 31, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided to the enrollee on 
May 5, 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 patient was enrolled in a Federal Hospice Program. 
 
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 a domiciliary or rest home visit provided to the enrollee on 
May 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says unproven and not medically 
necessary procedures are not covered by Medicare due to insufficient evidence of efficacy. 
 
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 intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental, and more research is needed. 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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the intracept procedure (CPT code 64628).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that a nurse is needed to come to the home for any 
necessary collection of blood and urine samples for laboratory testing. The Plan denied your request. The Plan 
says the clinical criteria for these services has not been met. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee does 
not have documented skilled nursing needs, as lab draws, in and of themselves, are not a home health skilled 
nursing need. The enrollee does not have documented skilled therapy needs.  There is no evidence of an acute 
illness/injury needing these services. 
 
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 pre-approve home health services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says unproven and not medically necessary procedures are not covered by 
Medicare due to insufficient evidence of efficacy. 
 
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 intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the request for intracept intraosseous 
basivertebral nerve ablation at L2, L3, L4, L5, and S1 is not medically reasonable or necessary. 
 
 
 
 
 
 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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT code 64628).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (ECG) monitoring and analysis 
provided on February 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the electrocardiogram (ECG) monitoring and analysis. You say that the service 
rendered falls under Medicare's guidelines of "Plan Directed Care."  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 
ECG monitoring and analysis. We found no exception that would require the Plan to pay for the ECG 
monitoring and analysis. Therefore, we decided that the Plan does not have to pay for the electrocardiogram 
(ECG) monitoring and analysis 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 pay for pathology services provided on November 1, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that these services were medically necessary and 
should be covered. The Plan denied your request. The Plan says 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. 
 
Neither the provider of the pathology services nor the referring provider is 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 pathology services 
provided on November 1, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test provided on February 20, 2022, while 
traveling outside the country. 
 
You asked the Plan to pay for the COVID-19 test. You say that you would like this claim reprocessed and 
approved for payment as you feel this copayment for a COVID-19 test is too high. The Plan denied your 
request. The Plan says there is no benefit for COVID-19 diagnostic tests when they are performed outside a 
laboratory, pharmacy, doctor, or hospital. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that COVID-19 tests will not be covered for travel as 
they are not medically necessary. Based on this information, we decided that Medicare rules for coverage of the 
COVID-19 test have not been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 
test provided on February 20, 2022, while traveling outside the country.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an echocardiography, transthoracic, real-time with 
image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler 
echocardiography, and with color flow Doppler echocardiography (93306). 
 
You asked the Plan to pre-approve an echocardiography. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says the requested service 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 an echocardiography. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee had documented atrial fibrillation in 2014, treated with medication, 
after which he has had no recurrence of symptoms. The new physician to whom his care has been transferred 
has ordered a trans-thoracic echocardiogram (TTE). The TTE has been ordered in the absence of any symptoms 
according to the submitted records. Clinical guidelines do not support carrying out a TTE in this setting. In 
summary, there is no supportive evidence for the medical necessity of a TTE in this this enrollees clinical 
management. 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 echocardiography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an echocardiography, transthoracic, real-time with image documentation (2D), 
includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with 
color flow Doppler echocardiography (93306).