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

 
We decided that the Plan does not have to pay for Drug Testing provided on October 29, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Drug Testing. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 Drug Testing provided on October 29, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an angiogram provided on November 17, 
2021. 
 
You asked the Plan to waive the coinsurance for an angiogram. You say that you were never told about the cost 
sharing amount before the procedure. You also say that this feels like an enormous amount for your part of the 
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 15% 
coinsurance for out-of-network outpatient surgery at an outpatient hospital.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$752.09, which is 15% coinsurance of the allowed amount for an angiogram ($5,013.94 allowed amount x 15% coinsurance = $752.09). An angiogram 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 coinsurance for an angiogram provided on November 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0425, 
A0427) provided on December 21, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
cost-sharing applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for Ambulance services.  
 
 
  You have been asked to pay a $125 copayment for ambulance transportation 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 ambulance transportation services (A0425, A0427) provided on 
December 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA 1 & 2 Sequence and full duplication/deletion 
(81162), and unlisted molecular pathology (81479). 
 
You asked the Plan to pre-approve genetic testing. You say that cancer runs in your family. You also say that 
you feel like this testing is medically necessary for you. The Plan denied your request. The Plan says the 
requested genetic testing is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing of an unaffected Medicare eligible 
individual or family member is not a covered Medicare benefit. 
 
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 genetic testing. Our reviewer says that 
the requested genetic testing is not medically necessary. Our physician reviewer found Medicare enrollees are 
not eligible for genetic testing without a diagnosis of cancer. The provided documentation indicates that are 
unaffected. Therefore, the reviewer found that at this time the service is not reasonable or medically 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 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BRCA 1 & 2 Sequence and full duplication/deletion (81162), and unlisted molecular 
pathology (81479).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attended diagnostic sleep study at a facility (95810). 
 
You asked the Plan to pre-approve sleep study. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says an attended diagnostic sleep study at a facility 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 sleep study. Our reviewer says that the 
requested in-home sleep study is not considered medically reasonable and necessary in this case. Our physician 
reviewer found an in-facility sleep study was requested to see if sleep apnea was related to these findings. The 
reviewer found that a home sleep study had not yet been completed nor was a home sleep study contraindicated 
in this clinical situation. The reviewer found that this request for an in-facility attended sleep study is not 
sufficiently supported and will be considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an attended diagnostic sleep study at a facility (95810).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy evaluation (97163) provided on June 15, 
2020. 
 You asked the Plan to pay for physical therapy. You say that these services were medically necessary and were 
billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 
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 the therapy services are not supported in the medical record. Specifically, the documentation 
shows that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a 
Physical Therapist. There is no indication that the Nurse Practitioner was present on site while the therapy 
services were being rendered. The incident-to requirements have not been met in this case. Based on this 
information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we 
decided that the Plan does not have to pay for the physical therapy evaluation (97163) provided on June 15, 
2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs or documented skilled therapy needs. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at 
a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve self-administered drugs provided from September 6, 
2021, to September 9, 2021. 
 
You asked the Plan to pre-approve self-administered drugs. You say that these drugs should be covered. The 
Plan denied your request. The Plan says the denial of payment for these drugs is correct, because self-
administered drugs are not covered by Medicare Part B except in limited circumstances and should be covered 
by your Medicare Part D prescription drug benefits instead. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve self-administered drugs 
provided from September 6, 2021, to September 9, 2021.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary services provided on November 3, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 Domiciliary services provided on November 3, 
2021 by an out-of-network (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 
December 31, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you didn't have a choice 
but to go to the emergency room. You say that due to COVID-19 you could not see a regular provider or urgent 
care. The Plan denied your request. The Plan says you have been charged the correct copayment 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 $110 
copayment for each covered emergency room visit. 
 
 
 You have been asked to pay a $110 copayment for an emergency room visit. 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 December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist office visit provided on August 
4, 2021. 
 
You asked the Plan to waive the deductible for a specialist office visit. You say that you were not supposed to 
be billed for this visit. 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. Your 
contract with the Plan says that there is $198 deductible which applies to a specialist office visit.  
 
 The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
Services, Including Doctors Office Visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $198 deductible which applies to a specialist office visit. This cost 
sharing is a contractual obligation that had not been met at the time a specialist office visit was received on 
August 4, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a specialist 
office visit provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient clinic visit provided on December 6, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the outpatient clinic visit. You say that you would like a retro authorization 
because the treatment provided to the enrollee was medically necessary. 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 an outpatient clinic visit provided on December 6, 
2021, by an OON provider.
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 
December 20, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the visit was a follow-up for your 
procedure and it should be covered. 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 $35 
copayment for specialist visits.  
 
You have been asked to pay a $35 copayment for the office visit. The office visit falls 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 a specialist office visit provided on December 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on November 12, 2021. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you received two bills in the amount of 
$150 each which is too high.  You say that you cannot pay these bills. The Plan denied your request. The Plan 
says you have been charged the correct copayment 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 $150 
copayment for Medicare-covered diagnostic procedures and tests.  
 
  
 
You have been asked to pay a $150 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 a CT scan provided on November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at-home COVID-19 self-tests purchased from January 12, 
2022, to January 14, 2022. 
 
You asked the Plan to pay for COVID-19 self-tests. You say that you were told by a plan representative that 
you could be reimbursed for these items. The Plan denied your request. The Plan says these tests are considered 
an OTC item, which means they are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and COVID-19 
self-tests are an OTC item. Therefore, we decided that the Plan does not have to pay for at-home COVID-19 
self-tests purchased from January 12, 2022, to January 14, 2022.  
 
Your complaint about potential misinformation from a Plan representative is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lipectomy of bilateral upper extremities, lower 
extremities, abdomen, and trunk (15879-50-22 x 2, 15878-50-22). 
 
You asked the Plan to pre-approve the lipectomy. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 lipectomy. Our reviewer says that 
the available documentation in the case file is insufficient to demonstrate that lipectomy of the bilateral upper 
extremities, lower extremities, abdomen, and trunk is medically reasonable and necessary for the enrollee in 
this case. Our reviewer found the photographic evidence does not support significant deformity from lipedema 
in the upper and lower extremities and abdomen and trunk, which would reasonably be expected to result in 
suffering "from severe limitations and restrictions due to the condition of lipedema which dramatically affects 
mobility, gait, etc.  
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 lipectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the lipectomy of bilateral upper extremities, lower extremities, abdomen, and trunk 
(15879-50-22 x 2, 15878-50-22).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient clinic services provided on December 21, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the claim 
was not billed in accordance with guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The Medicare Claims Processing Manual Citation (Chapter 19, Section 
100.5.1), the Plan used in their decision to deny services is billing guidelines for Indian Health Services. The 
case file does not show that the provider at issue falls under Indian health care system. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request.  Therefore, we decided that the Plan has to pay for the outpatient clinic services provided on December 
21, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that this procedure is recommended when conservative 
treatment has failed and as a safer alternative to a laminectomy or spinal fusion. The Plan denied your request. 
The Plan says the denial of authorization for this service is correct, because Vertiflex is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental, 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.