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

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel, 51 or greater 
genes (81455) provided March 16, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that this letter and the attached documents 
support the medical necessity of the tests requested. The Plan denied your request. The Plan says medical 
necessity cannot be established. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of targeted genomic sequence analysis 
panel, 51 or greater genes (81455) provided March 16, 2022. have been met. Medical records were not 
provided to support the medical necessity. Instead, the appellant provided an overview of how NGS can impact 
the choice of treatments and pathology report which does not support the criteria. The Plan made multiple 
attempts to obtain the medical records from the provider without success. Therefore, we decided that the Plan 
does not have to pay for targeted genomic sequence analysis panel, 51 or greater genes (81455) provided 
March 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation clearly shows that enrollee has functional decline and would benefit from skilled therapy. The enrollee has impairments that would require skilled physical therapy and 
occupational therapy (two disciplines of therapy) however there is no documentation to show that the enrollee 
has active clinical complications or comorbidities that would require 3 physician visits per week on an inpatient 
basis as only information regarding functional decline is documented. Thus, IRF criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on February 24, 
2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this 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 the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not support that other means of transport were contraindicated. The enrollee did not need 
the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can 
provide for safe transport on 2/24/22. 
 
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 February 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided May 7, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that it does not make sense for you to be 
penalized when you saved the Plan money by not going to the hospital. The Plan denied your request. The Plan 
says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on May 7, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided May 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional chest x-ray provided to the enrollee on March 
9, 2022. 
 
You asked the Plan to pay for the additional exam. You say that the claim was denied as duplicate in error. The 
Plan denied your request. The Plan says a call to the hospital confirmed that only one chest x-ray was rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
There is no evidence that multiple chest x-rays were performed on this date of service. Based on this information, we decided that Medicare rules for coverage of the additional exam have not been met. Therefore, 
we decided that the Plan does not have to pay for an additional chest x-ray provided to the enrollee on March 9, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
November 3, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the scanning of computerized ophthalmic 
diagnostic imaging provided on May 9, 2022. 
 
You asked the Plan to waive the copayment for the scanning of computerized ophthalmic diagnostic imaging. 
You say that you are appealing with supporting records. The Plan denied your request. The Plan says you were 
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 $75 
copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service except certain 
exclusions.  
  You have been asked to pay $27, which is less than the $75 copayment for the scanning of computerized 
ophthalmic diagnostic imaging. The scanning of computerized ophthalmic diagnostic imaging 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 the scanning of computerized ophthalmic diagnostic imaging provided on May 9, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on April 20, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the surgery services. You say that the services rendered to the enrollee was out of 
medically necessity. 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 surgery services provided on April 20, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on February 8, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. 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 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. The 
records provided for review do not show that the laboratory work was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on February 8, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on December 27, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior 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 drug testing provided on December 27, 2021 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT scan) of the 
head provided on April 6, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you are appealing the copayment 
because you unknowingly enrolled in the health plan. 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 $180 
copayment for advanced imaging services.  
 
You have been asked to pay a $180 copayment for the CT scan. The CT scan 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 the computed tomography (CT scan) of the head provided on April 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing coded 81455 provided on April 5, 2022. 
 
You asked the Plan to pay for the testing coded 81455. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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. 
 
 
 
 We find that CPT code 81455 is not supported in the medical record. Specifically, the documentation shows 
that the specimen was collected on March 14, 2022. This means the documentation does not support the date of 
service April 5, 2022. Based on this information, we decided that Medicare rules for coverage of the testing 
coded 81455 have not been met. Therefore, we decided that the Plan does not have to pay for the testing coded 
81455 provided on April 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig provided on January 5, 2022. 
 
You asked the Plan to pay for the wig. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says a wig is not covered by Medicare or the Plan. 
 
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 pay for the wig provided on 
January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the LifeVest system provided on May 26, 2021. 
 
You asked the Plan to pay for the LifeVest system. You say that your organization was having system issues 
and was not aware that this claim hadn't been filed. The Plan denied your request. The Plan says [Enter plan 
denial rationale, e.g. "...rules for SNF care have not been met."] 
 
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 LifeVest system was not filed until June 15, 2022. 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 LifeVest system provided on May 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you didn't call this 
service, and if you had known how high the copayment was you would have arranged a different ride. The Plan 
denied your request. The Plan says you were charged this cost sharing 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 $300 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $300 for these 
services. 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 the ambulance services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the in-home skilled nursing visits provided from July 1, 
2021, to July 23, 2021. 
 
You asked the Plan to pay for the home health care. You say that this claim should be paid. The Plan denied 
your request. The Plan says the home health certification and plan of care is not signed by the treating 
physician to certify that the enrollee is homebound and requires the help of a skilled nurse. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care have not been met. Specifically, the documentation submitted does not 
include a valid signature from the persons responsible for the care of the beneficiary. The file shows that there 
is no signature from the treating physician. Therefore, we decided that the Plan does not have to pay for the in-
home skilled nursing visits provided from July 1, 2021, to July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
January 31, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that this is your secondary insurance, 
and you should not have to pay a copay when you have additional coverage. The Plan denied your request. The 
Plan says the copayment applied was 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 a $25 
copayment for each in-network specialist or any other physician or other health care professional visit for 
Medicare-covered benefits in a specialist setting.  
 
You have been asked to pay a $25 copayment for a specialist office visit. A specialist 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 copayment for a specialist office visit provided 
on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program (99204) provided on April 25, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that the service should be covered. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
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 the ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program (99204) provided on April 25, 
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 moderate sedation services (99153) provided on February 
15, 2022. 
 
You asked the Plan to pay for code 99153. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the review shows that the medical records provided 
represent professional charges; however, procedure code 99153 was provided in a facility with a place of 
service code of 23. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services (99153) provided on February 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided February 16, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you don't understand why the ambulance 
service is not covered. The Plan denied your request. The Plan says this service is not covered when there is no 
transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on February 16, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided February 16, 2022.