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

 
We decided that the Plan does not have to pay for lab services provided on April 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychosocial rehabilitation services, per 15 minutes 
(H2017) rendered by the out-of-network (OON) provider from July 19, 2021, through August 22, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the psychosocial rehabilitation services, per 15 minutes (H2017) rendered by the 
out-of-network (OON) provider from July 19, 2021, through August 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient Wound care procedures on 
August 26, 2021 to September 16, 2021 
 
You asked the Plan to waive the copayments for Wound care. You say that you do not agree with the amount 
of cost share assessed. The Plan denied your request. The Plan says the copayment you are being charged 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 a $225 
copayment for each outpatient Wound care procedure. The total allowed amount is $692.36 which is less than 
the $900 copayment from four total visits. 
 
 
 
 
 
 You have been asked to pay a $225 copayment for each outpatient Wound care procedure. Wound care falls 
within the Outpatient Hospital Services 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 copayments 
for outpatient Wound care procedures on August 26, 2021 to September 16, 2021
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thoracic computed tomography (CT) scan (71250). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve the CT scan. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found no chest pathology was noted on x-ray. The 
record supports that the symptoms are likely due in large part to a swallowing disorder and active 
gastroesophageal reflux.   
 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a thoracic computed tomography (CT) scan (71250).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
October 31, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the copayment should be waived due 
to your COVID-19 diagnosis. 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 $90 
copayment per visit for emergency care.  
 
The file shows that the Plans COVID-19 cost share waiver ended on May 31, 2021. Therefore, you have been 
asked to pay a $90 copayment for the ER visit. The ER 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 (ER) visit provided on October 31, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing (81479) provided on May 13, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
this testing was billed correctly. The Plan denied your request. The Plan says this claim was not billed with the 
correct POS code. 
 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 Guardant360 testing 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 the Guardant360 testing (81479) provided on May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 July 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the requested service. You say that the enrollee has severe arthritis The Plan 
denied your request. The Plan says coverage criteria have not been met. The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical indications. 
 
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 requested service. Our physician 
reviewer found that in this case, the enrollee has documented sciatica, but no spinal imaging to indicate that 
there is disc herniation, osteophyte or osteophyte complexes, degenerative disc disease, or spinal stenosis. The 
review has determined that the coverage criteria for the requested epidural steroid injection have 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 the requested service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee arthroscopy (29881). 
 
You asked the Plan to pre-approve the knee arthroscopy (29881). You say that you have left knee pain that 
worsened after a fall which created lack of movement and mobility due to a torn meniscus. You say that you 
won't be able to do any therapy before surgery. The Plan denied your request. The Plan says the criteria for 
coverage has not been met and the requested procedure cannot be approved. 
 
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 knee arthroscopy (29881). Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that detailed documentation is not evident regarding trial and failure of 
recent, reasonable, and comprehensive less invasive conservative care measures. Additionally, there is limited 
published literature that shows the requested knee surgery to be an effective and/or safe treatment with 
presence of significant degenerative changes/osteoarthritis. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
  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 knee arthroscopy (29881) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the knee arthroscopy (29881).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for the evaluation and management of an 
established patient (99347), the paring or cutting of benign hyperkeratotic lesions (11056), and the trimming of 
non-dystrophic nails (11719) rendered by the out-of-network (OON) provider on May 19, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the home visit for the evaluation and management of an established patient 
(99347), the paring or cutting of benign hyperkeratotic lesions (11056), and the trimming of non-dystrophic 
nails (11719) rendered by the out-of-network (OON) provider on May 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcervical carotid stenting (37215). 
 
You asked the Plan to pre-approve transcervical carotid stenting. You say that this service is medically 
necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of this 
service. 
 
The Plan follows Medicare rules. Medicare rules say that transcervical carotid stenting may be covered when 
used under the following conditions: 
 1. Treatment of Atherosclerotic Obstructive Lesions 
 
2. Concurrent with Carotid Stent Placement in Food and Drug Administration (FDA)-Approved Category B 
Investigational Device Exemption (IDE) Clinical Trials 
 
3. Concurrent with Carotid Stent Placement in FDA-Approved Post Approval Studies 
 
4. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) 
 
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 transcervical carotid stenting. Our 
reviewer says that transcervical carotid stenting is not medically necessary at this time. Our physician reviewer 
found to qualify, you must also be enrolled by the provider/facility in a clinical trial or established 
database.  As transcervical carotid stenting, while holds promise, is relatively new, the requirement that you be 
enrolled in a study or recognized database is a reasonable condition of coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transcervical carotid stenting have not been met. Therefore, we decided that the 
Plan does not have to pre-approve transcervical carotid stenting (37215).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 21, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the provider is an in-network provider with the Plan 
and the claim should be paid. 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 an office visit provided on September 21, 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 August 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 August 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 
15, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you should not be financially 
responsible for the charge. The Plan denied your request. The Plan says the copayment amount charged 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 a $250 
copayment for each Medicare-covered ground ambulance transport.  
 
 You have been asked to pay a $225 copayment, which is less than the Plan's EOC documented $250 copayment 
for ambulance services. Ambulance services fall within the Ambulance Services 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 ambulance services provided on October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne testing (81455) provided on August 23, 
2021. 
 
You asked the Plan to pay for FoundationOne testing. You say that this was medically necessary. The Plan 
denied your request. The Plan says this is not covered. 
 
  The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted code 81455 
are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied 
automatically as not medically necessary.  
 
We looked at the file and Medicare rules. The testing at issue was submitted with code 81455 and is not 
considered medically necessary. Based on this information, we decided that Medicare rules for coverage of 
FoundationOne testing have not been met. Therefore, we decided that the Plan does not have to pay for 
FoundationOne testing (81455) provided on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 1, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim must be 
submitted to the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for the services provided on October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) and the prolonged office or other 
outpatient evaluation and management service (G2212) rendered by the out-of-network (OON) provider on 
August 18, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the office visit (99215) and the prolonged office or other outpatient evaluation 
and management service (G2212) rendered by the out-of-network (OON) provider on August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 27, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 August 27, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Emergency care on September 30, 2021. 
 
You asked the Plan to waive the copayment for Emergency care. You say that you do not agree with the 
charge. The Plan denied your request. The Plan says the copayment you are being charged 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 a $90 
copayment per visit for Emergency care.  
 
You have been asked to pay a $90 copayment per visit for Emergency care. Emergency care 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 Emergency care on 
September 30, 2021.