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

 
We decided that the Plan does not have to waive the $94.96 copayment for an ultrasound performed on May 
17, 2021. 
 
You asked the Plan to waive the $94.96 copayment for an ultrasound performed on May 17, 2021. You say that 
you were not aware there would be an extra charge for this. The Plan denied your request. The Plan says you 
are responsible to pay a $94.96 copayment for an ultrasound. 
 
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 $105 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $94.96 copayment for an ultrasound performed on May 17, 2021. An ultrasound 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. Your 
contract with the Plan clearly says that you must pay a $105 copayment for Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies. However, since the Plans allowance for this service was $94.96, which is 
less than the $105 copayment amount, you have only been asked to pay the lesser amount. 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 $94.96 copayment for an ultrasound performed on May 17, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
February 27, 2022. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says the 
Plan needs an Explanation of Benefits (EOB) from the primary insurance carrier. 
 
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 received an 
EOB from the primary insurance carrier. As the secondary insurer, the Plan cannot be held responsible for the 
emergency department visit until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit provided on February 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390) provided on March 19, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the oxygen concentrator. You say that this is a monthly charge. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the oxygen concentrator (E1390) provided on 
March 19, 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 Tempus Gene Panel testing provided January 30, 2022. 
 
You asked the Plan to pay for the molecular pathology testing. You say that you request reconsideration of this 
determination and coverage of the Tempus Gene Panel test at the in-network benefit level. The Plan denied 
your request. The Plan says does not meet Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we find that the molecular pathology testing is not supported in the medical record. Specifically, 
Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one 
CPT code must be submitted for the panel. Based on this information, we decided that Medicare rules for 
coverage of the molecular pathology testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the Tempus Gene Panel testing provided January 30, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for ambulance transport provided on February 
26, 2022. 
 
You asked the Plan to reduce the copayment for ambulance transport. You say that this should be reduced to 
$125 copayment total since you were told that's how much it would cost. The Plan denied your request. The 
Plan says the copayment applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $125 copayment per one-way trip for Medicare-covered ambulance services.  
 
The enrollee has been asked to pay $250 ($125 each way) copayment for ambulance transport. Ambulance 
transport falls within the Ambulance Services benefit category. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce 
the copayment for ambulance transport provided on February 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you appear to be more stable and improving but requires short-term additional acute 
care services that can be safely completed at the current facility until more appropriate for a lower level of care 
including more stable feeding status. There are no services at the LTACH that you require that are not already 
available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be 
clinically advantageous. Completion of treatment at the current facility is recommended. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the personal electrocardiogram (EKG) device and heart 
monitor case purchased on January 31, 2022. 
 
You asked the Plan to pay for the personal EKG device and heart monitor case. You say that you feel this 
device is an aid to your better health as a fitness club, personal trainer, or at-home fitness equipment would be. 
You also say that you believe this device should be covered. The Plan denied your request. The Plan says this 
device is not covered under your Wellness Wallet benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. However, the Plan offers a Wellness Wallet benefit that exceeds Medicare coverage. For that 
reason, the Plans coverage rules apply in this case.  
 Though the Plan offers a Wellness Wallet benefit in excess of Medicare coverage, the requested items or 
services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the personal electrocardiogram (EKG) device and heart monitor case purchased on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99152) billed for date of service 
December 8, 2021. 
 
You asked the Plan to pay for moderate sedation services. You say that you have provided medical records to 
support the services at issue. The Plan denied your request. The Plan says rules for payment have not been met 
because the available medical records do not support the service 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. 
 
 
 
 
 In this case, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the available medical 
records do not support that the moderate sedation services were provided in the presence of an independent 
trained observer. Based on this information, we decided that Medicare rules for coverage of moderate sedation 
services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation 
services (99152) billed for date of service December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on March 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for podiatry services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services were 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 podiatry services provided on March 18, 2022, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is inappropriate for the Plan to block 
the transfer on the unfounded reason that there is lack of medical necessity. You also say that there are 
qualified specialty hospital services available that could greatly benefit the enrollee. The Plan denied your 
request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently unstable for 
transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no evidence that the enrollee requires services that are not currently available. 
As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. Our reviewer also found that the enrollee can remain at 
the current ACH until such time no acute services are required.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
September 15, 2020. 
 
You asked the Plan to pay for an emergency department visit. The Plan denied your request. The Plan says 
Medicare denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 
calendar year from the date the services were furnished. 
 
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 an emergency department visit was not filed until February 18, 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 an emergency department visit provided on 
September 15, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for moderate sedation services (procedure code 99153) provided to the 
enrollee on August 26, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the place of service was inappropriate for this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 99153 is "Moderate sedation services provided by the same physician or other qualified health care 
professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence 
of an independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; each additional 15 minutes intraservice time (list separately in addition to code for 
primary service)." 
 
We asked our coder 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 supported by the medical records. Our reviewer found that the medical records indicate that the 
use of two units of CPT 99153 is accurate, with the sedation time listed as 13:36-14:18. With the initial 
sedation procedure code being CPT 99152, and two units of CPT 99153, the place of service is correct as the 
place of service is the same for the whole claim and all procedures. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
moderate sedation services (procedure code 99153) provided to the enrollee on August 26, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheeled walker provided on February 15, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the wheeled walker. You say that you were told you would be reimbursed. You 
were told that the Plan would pay 70% and you would pay 30%. 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 
wheeled walker. We found no exception that would require the Plan to pay for the wheeled walker. The records 
provided for review do not show that the wheeled walker was urgent or emergent. Therefore, we decided that 
the Plan does not have to pay for the wheeled walker provided on February 15, 2022, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted multianalyte assay with algorithmic analysis (81599) 
provided September 7, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the requisition form confirms the test was 
ordered by the enrollee's treating physician with the intent to use the test results to inform treatment decisions. 
The Plan denied your request. The Plan says not otherwise classified or unlisted procedure code was billed 
when there is a specific procedure code for this procedure/service. 
 
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 unlisted multianalyte assay with 
algorithmic analysis (81599) provided September 7, 2021. have been met. Medical records was required to 
determine how the enrollee came to the servicing provider or whether the services were medically necessary. 
The Plan made multiple attempts to obtain records from the provider without success. Therefore, we decided 
that the Plan does not have to pay for unlisted multianalyte assay with algorithmic analysis (81599) provided 
September 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a shoulder orthosis provided on March 1, 
2022. 
 
You asked the Plan to waive the deductible for a shoulder orthosis provided on March 1, 2022. You say that no 
information was given to you that this would be an out-of-network charge. The Plan denied your request. The 
Plan says $99.21 was applied correctly to your combined annual deductible. 
 
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 $400 combined annual deductible which applies to a shoulder 
orthosis. 
 
 
 
 
 
 
 
 
 
 The item or service you asked the Plan to waive the deductible for falls within the benefit category Durable 
Medical Equipment (DME) and Related Supplies. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is a $400 combined annual deductible which applies to durable medical equipment. 
This cost sharing is a contractual obligation that had not been met at the time a shoulder orthosis was received 
on March 1, 2022. Therefore, we decided that the Plan does not have to waive the $99.21 deductible for a 
shoulder orthosis provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on March 3, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological 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 ophthalmological services provided on March 3, 
2022, by an out-of-network (OON) provider.