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

 
We decided that the Plan does not have to pay for a telehealth visit provided on November 8, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth visit. You say that the provider is an in-network provider, and the 
services are payable. Also, the service rendered to the enrollee was medically necessary. The Plan denied your 
request. The Plan says the rendering provider is an out-of-network 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 a telehealth visit provided on November 8, 2021, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are covered by Medicare. The Plan 
denied your request. The Plan says you billed with 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 May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on November 18, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says they followed up with the member's primary care physician (PCP) office 
and was advised by the office representative that there was no referral on file for date of service November 18, 
2021. The Plan also says that the services were billed by and rendered by a non-participating provider, and they 
have also determined that these services are not urgent or emergent, nor were they approved in advance. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on November 18, 
2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the 
enrollee was admitted with endocarditis. The record indicates that the enrollee requires ongoing acute care 
services. The enrollee continues to receive acute care services, and these have not been denied. The medical 
record does not indicate that the enrollee requires services that she is not currently receiving but that would be 
available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service 
cannot be recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration because 
the LTACH admission is medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for the LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is 
currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because 
the SNF admission is medically necessary. The Plan denied your request. The Plan says you do not meet 
criteria for coverage of the SNF admission. 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found based on the medical records 
provided you do not appear to be medically stable to transfer to a skilled nursing facility due to your on going 
conditions. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Skilled Nursing Facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex procedure. 
 
You asked the Plan to pre-approve the Coflex procedure,. You say that you would like reconsideration because 
this procedure is medically necessary. The Plan denied your request. The Plan says this procedure is 
experimental. 
 
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 Coflex procedure,. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is experimental and more research is needed to show its safety and 
efficacy. 
 
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 Coflex procedure, have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Coflex procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit for dental services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that the requested provider is the only provider in 
your area that specializes in the pain management treatment you need. You also say the root of the pain is due 
to migraines and your quality of life is severely impacted. The Plan denied your request. The Plan says the 
requested provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 
 
 
 The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. We have confirmed that the provider opted out of Medicare on August 
5, 2020. Therefore, we decided that the Plan does not have to pre-approve an office visit for dental services 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 incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that in January 2022 your doctors concluded 
you could no longer tolerate a catheter and you were required to return to using paper diapers. You also say that 
you feel the Plan should cover the incontinence supplies because the cost of these supplies is less than the 
amount the Plan was paying to cover the catheter maintenance. The Plan denied your request. The Plan says 
incontinence supplies are statutorily excluded from coverage because they are non-reusable, and they do not 
meet Medicares definition of durable medical equipment (DME). 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are covered by Medicare. The Plan 
denied your request. The Plan says you billed with 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 May 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
November 9, 2021. 
 
You asked the Plan to waive the copayment for the mammogram. You say that the first test was unreadable so 
you had to return for a second test. 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 $100 
copayment for diagnostic tests and procedures at an outpatient hospital.  
 
The record shows that the test was done due to possible abnormal results from the first test. Therefore, you 
have been asked to pay a $100 copayment for the mammogram. The mammogram 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 waive 
the copayment for a diagnostic mammogram provided on November 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bavencio (CPT code J9023). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary for the enrollee's 
treatment of colon cancer. The Plan denied your request. The Plan says the documentation does not support that 
the enrollee has: an accepted medical indication for Bavencio. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of Stage IV colon cancer. The requested drug is 
being used as second line treatment. The Food and Drug Administration has not stated that the requested drug 
is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a 
supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from 
Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not 
satisfied. The requested service cannot be recommended. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Bavencio (CPT code J9023).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for an echocardiogram provided on October 21, 
2021. 
 
You asked the Plan to lower the copayment for an echocardiogram. You say that the copayment for this service 
should only be $10. The Plan denied your request. The Plan says the proper copayment was applied for the 
service rendered by a specialist. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for diagnostic tests by a Specialty Physician.  
 
  You have been asked to pay a $20 copayment for an echocardiogram. An echocardiogram 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 lower the copayment for an echocardiogram provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy (90833, 99213) provided on November 3, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that as per credentialing status, the provider is enrolled 
and in-network with the Plan. You also say that services are payable, and the Plan is responsible to pay the 
provider. The Plan denied your request. The Plan says the rendering provider is a non-participating provider, 
and there is no referring provider involved in these services. The Plan also says that they did not authorize any 
services for this provider. 
 
 
 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 psychotherapy (90833, 99213) provided on 
November 3, 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 laboratory services provided on November 12, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services provided to the enrollee was 
medically necessary. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
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 laboratory services provided on November 12, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet rich plasma injections (0232T). 
 
You asked the Plan to pre-approve platelet rich plasma injections. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this service is considered experimental and non-
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Platelet rich plasma injections and/or 
applications are considered not medically reasonable and necessary for any use outside of the National 
Coverage Determination (NCD) 270.3 Blood-Derived Products for Chronic Non-Healing Wounds. 
 
We looked at the file and Medicare rules. The request is not for treatment of Chronic Non-Healing wounds and 
is therefore considered non-covered under Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of platelet rich plasma injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve platelet rich plasma injections (0232T).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the coinsurance for the colonoscopy with lesion removal  
(45384) and the esophagogastroduodenoscopy, flexible, transoral; diagnostic (43235) provided on October 12, 
2021. 
 
You asked the Plan to adjust the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
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 20% coinsurance for Medicare-covered surgery or 
other services at an outpatient hospital or ambulatory surgical center, including but not limited to hospital or 
other facility charges and physician or surgical charges.  
 
You have been asked to pay $273.70 (196.85 +$76.85). This includes the Plans allowed amount of  
$984.26 x 20% coinsurance= $196.85 for the colonoscopy with lesion removal provided. Additionally, this 
includes the Plans allowed amount of $384.23 x 20% coinsurance=$76.85 for the endoscopy provided at the 
outpatient hospital. These services provided fall in the Medicare-covered surgery 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 adjust the coinsurance for the colonoscopy with lesion removal  (45384) and the 
esophagogastroduodenoscopy, flexible, transoral; diagnostic (43235) provided on October 12, 2021.