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

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463), the laboratory 
service (80061), and the routine venipuncture (36415) rendered by the out-of-network (OON) provider on 
November 17, 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 hospital outpatient clinic visit (G0463), the laboratory service (80061), and 
the routine venipuncture (36415) rendered by the out-of-network (OON) provider on November 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement, muscle and/or fascia (includes epidermis, 
dermis, and subcutaneous tissue, if performed) provided on December 14, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the debridement, muscle and/or fascia (includes epidermis, dermis, and 
subcutaneous tissue, if performed). You say that the service was rendered due to medical necessity and patient 
care was provided as an urgent request from medical director/skilled nursing facility/primary care physician to 
avoid wound complications such as: deterioration, amputation, infection and or hospitalization. The Plan 
denied your request. The Plan says the request is for services by a non-contracted provider for the date of service, December 14, 2021. The Plan also says there is no referral letter from an in-network physician and the 
services were not medically necessary. 
 
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 debridement, muscle and/or fascia (includes 
epidermis, dermis, and subcutaneous tissue, if performed) provided on December 14, 2021, by an out-of-
network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services, 42 hours per week. 
 
You asked the Plan to pre-approve home health care. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 
 
 We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health care have not been met. Specifically, the record indicates that you need help with 
activities of daily living. This is considered custodial in nature and not covered by Medicare. Therefore, we 
decided that the Plan does not have to pre-approve home health aide services, 42 hours per week.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the heart for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request does not meet the medical necessity clinical guidelines. 
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the rules do not allow 
for screening coronary calcium scoring in patients who are asymptomatic. As such, this patient does not fulfill 
criteria per regulations for the requested CT calcium scoring. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) of the heart for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0242U) rendered by 
the out-of-network (OON) provider on December 23, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the targeted genomic sequence analysis (0242U) rendered by the out-of-network 
(OON) provider on December 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an echocardiography (ECG) (93306) 
provided on December 15, 2021. 
 
You asked the Plan to waive the deductible for the ECG. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the deductible 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. Your 
contract with the Plan says that there is a $750 deductible which applies to Outpatient diagnostic tests and 
therapeutic services and supplies.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible which applies to Outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
the ECG was received on December 15, 2021. Therefore, we decided that the Plan does not have to waive the 
deductible for an echocardiography (ECG) (93306) provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99336) rendered by the out-of-network (OON) provider on April 13, 
2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plans 
denial for payment.  The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99336) rendered by the out-of-network (OON) provider on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision care provided on  
November 30, 2021. 
 
You asked the Plan to waive the copayment for vision care. The Plan denied your request. The Plan says the 
claim processed with the appropriate copayment. 
 
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 $10 
copayment for Vision Care.  
 
You have been asked to pay $10 copayment for vision care. The vision care falls within the Vision 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 vision care provided on November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient observation provided by a 
network facility on August 18, 2021. 
 
You asked the Plan to waive the copayment for the outpatient observation. You say that there is a greater 
chance of being billed the remainder of the billed charged and your total out-of-pocket expenses vastly 
increasing in undue financial burden which goes against the intent of the Affordable Care Act. The Plan denied 
your request. The Plan says you have been asked to pay 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 $250 
copayment for in-network outpatient hospital observation services.  
 
 You have been asked to pay a $250 copayment for the outpatient observation. The outpatient observation falls 
within the Outpatient Hospital Observation benefit category. The record shows you were admitted to 
observation during your hospital stay.  
 
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 outpatient observation provided by a network facility on 
August 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on May 1, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that by the 
time the ambulance arrived you started to feel better. You also say that you told the paramedics that you did not 
need to be transported to the hospital when they asked you. The Plan denied your request. The Plan says 
ambulance services is a transport benefit, and it is only payable when you are transported to a hospital. The 
Plan also says that if an ambulance is called and you receive care, but decide not to be transported to a hospital, 
those services are not covered. 
 
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 1, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on May 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a genetic test performed on September 1, 
2021. 
 
You asked the Plan to waive the coinsurance for the genetic test. You say that the provider informed you there 
would be no charge for the test. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
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 genetic testing.  
 
You have been asked to pay $774.60, which is 20% of the allowed amount for the genetic test ($3,873.00 
allowed amount x 20% coinsurance = $774.60). The genetic test 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 coinsurance 
for a genetic test performed on September 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the adjacent tissue transfer and Mohs 
procedure provided on June 12, 2021. 
 
You asked the Plan to waive the coinsurance for the adjacent tissue transfer and Mohs procedure. You say that 
you paid a $45 copayment, and the Plan has only made partial payment. You say that you received an invoice 
of $543.93 and you don't understand why you are being billed for this service. The Plan denied your request. 
The Plan says the coinsurance applied correctly. 
 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% 
coinsurance for provider and professional services at an out-of-network specialist's office.  
 
You have been asked to pay a total of $543.93 for the adjacent tissue transfer and Mohs procedure.  
 
Service Allowed Amount Out-of-Network Coinsurance Member Liability 
Adjacent Tissue Transfer $755.34 50% $377.67 
Mohs Procedure $332.52 50% $166.26 
TOTAL:   $543.93 
 
The adjacent tissue transfer and Mohs procedure fall within the "Physician/Practitioner services, including 
doctor's office visits" benefit category. The records show the services were received from an out-of-network 
specialist. 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 the adjacent tissue transfer and Mohs 
procedure provided on June 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound (76705) provided on 
November 14, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. 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 $50 
copayment for Pruebas de diagnostico ambulatorias y servicios y suministros terapeuticos.  
 
 
  You have been asked to pay a $50 copayment for an ultrasound. Ultrasounds fall within the Pruebas de 
diagnostico ambulatorias y servicios y suministros terapeuticos 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 ultrasound (76705) provided on November 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air fluidized bed (E0194) provided November 1, 2021. 
 
You asked the Plan to pay for the air bed. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says the records do not support the service billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order and relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the physician's order does not include the length of 
need for the durable medical equipment. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the air 
fluidized bed (E0194) provided November 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on December 25, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that when the 
ambulance arrived at your house you were ready to go with them. You also say that they informed you they 
could transport you, but there was no room anywhere for you to go close by. The Plan denied your request. The 
Plan says this service is not covered under your contract under any normal circumstances. 
 
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 December 25, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The records show that you were asked what your wishes regarding transportation were, and you declined to be 
taken to the emergency room for further evaluation. Therefore, we decided that the Plan does not have to pay 
for the ambulance response and treatment with no transport (A0998) provided on December 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a brace and sleeve provided to the enrollee on October 20, 
2021. 
 
You asked the Plan to pay for the services. You say that this shouldn't have denied. The Plan denied your 
request. The Plan says the listed ordering provider denies ordering this item. 
 
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. Medicare rules also say that durable medical equipment generally must be 
ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. 
 
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 a brace and sleeve provided to the enrollee on October 20, 2021. have been met. The provider did not send any information showing that a valid 
treating physician ordered this item. The file does not contain documentation of an established relationship 
between the ordering provider and the durable medical equipment company.. Therefore, we decided that the 
Plan does not have to pay for a brace and sleeve provided to the enrollee on October 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomographic angiography 
(CTA) of the head (70496) provided on August 24, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 advanced imaging services provided by an in-network freestanding radiological facility.  
 
 You have been asked to pay a $125 copayment for the advanced imaging service provided by an in-network 
freestanding radiological facility. 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 
tomographic angiography (CTA) of the head (70496) provided on August 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance response and treatment with 
no transport (A0998) provided on December 25, 2021. 
 
You asked the Plan to waive the copayment for an ambulance response and treatment with no transport. You 
say that your daughter called the ambulance service to come and do a wellness check and when they arrived at 
your home, they did some basic tests on you. You also say they informed you that they could transport you, but 
there was no room anywhere for you to go, so you spoke to your daughter, and you all made the decision for 
you to stay home and keep doing what you were doing. 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 $300 
copayment for ambulance services.  
 
You have been asked to pay $225, which is less than the $300 copayment for an ambulance response and 
treatment with no transport. An ambulance response and treatment with no transport falls 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 an ambulance response and 
treatment with no transport (A0998) provided on December 25, 2021.