Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an earwax removal office visit provided on July 11, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an earwax removal office visit. You say that the patient needed this service and it 
should be covered. The Plan denied your request. The Plan says there was no preauthorization by a primary 
care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was 
not an emergency. Therefore, the decision is upheld. 
 
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 earwax removal office visit provided on July 
11, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit, a radiologic examination of the 
mandible, and a radiologic examination of the teeth. 
 
You asked the Plan to pre-approve an office visit, a radiologic examination of the mandible, and a radiologic 
examination of the teeth. You say that the Plan should cover these services. The Plan denied your request. The 
Plan says the enrollee is under hospice care and the services should be submitted to original Medicare for 
coverage. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Since the 
enrollees hospice has ended, a new request for coverage should be made. Therefore, we decided that the Plan 
does not have to pre-approve an office visit, a radiologic examination of the mandible, and a radiologic 
examination of the teeth.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee is at high risk for hospital 
readmission. The Plan denied your request. The Plan says the requested therapy can be provided with a BiPAP. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our physician reviewer 
found that the enrollee has severe COPD, with mild chronic carbon dioxide (CO2) retention documented on the 
arterial blood gas (ABG) as an outpatient. The enrollee may benefit from BiPAP during sleep. This has not 
been tried and failed. However, Medicare does not cover a home ventilator when used at settings that can be 
provided by BiPAP. Therefore, a home ventilator is not 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist visits provided on May 19, 2022, and June 7, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for specialist visits. You say that you are requesting a review of the medical records 
to show necessity and to reprocess claim for payment. The Plan denied your request. The Plan says an 
authorization was not obtained prior to services rendered. 
 
  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 specialist visits provided on May 19, 2022, and 
June 7, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the low dose computed tomography (LDCT) scan for lung cancer 
screening provided on June 7, 2022. 
 
You asked the Plan to pay for the LDCT scan. You say that the procedure was performed at the request of the 
referring doctor, as the enrollee's medical condition proved the medical necessity for the service. The Plan 
denied your request. The Plan says that this service has been denied because it was not reported with an 
approved diagnosis. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan denied this LDCT scan because it was billed with a 
diagnosis of Z12.2, defined as encounter for screening for malignant neoplasm of respiratory organs. We find 
that this diagnosis is not inappropriate for this service, because it is for a lung cancer screening, which is what 
the LDCT scan is for. It is not indicated that the enrollee already has lung cancer, but that it was being screened 
for. We also find that the Plan did not provide information on the enrollee's smoking history, and if, or when, 
they quit. Therefore, we find that the Plan has not supported their denial of payment in this case. Therefore, we 
decided that the Plan has to pay for the low dose computed tomography (LDCT) scan for lung cancer screening 
provided on June 7, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens fitting (92310) provided on July 1, 2022. 
 
You asked the Plan to pay for the contact lens fitting. You say that you do not understand why you have to pay 
for this. You also say you cannot wear glasses, and this falls under medical because you have glaucoma. The 
Plan denied your request. The Plan says this service is not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. Although you have a $200 allowance per year for routine 
prescription eyewear, contact lens fitting is not listed as a covered service. Based on this information, we 
decided that the Plan's rules for coverage of the contact lens fitting have not been met. Therefore, we decided 
that the Plan does not have to pay for the contact lens fitting (92310) provided on July 1, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the non-emergency ambulance transportation (A0426) and ground 
mileage (A0425) provided on March 2, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the enrollee was discharged after being seen in the emergency room, and was then admitted to the hospital they 
were transported to. The Plan denied your request. The Plan says that the ambulance services that incurred 
while the enrollee was confined as an inpatient are included in the inpatient contractual allowed amount. 
 
The Plan must follow Medicare rules. Medicare rules say that if both the origin and destination of the 
ambulance transport are providers, then responsibility for payment for the ambulance transport is determined in 
accordance with sequential criteria. Medicare rules also say if the Medicare-assigned provider numbers of the 
two providers are different, then the ambulance service is separately billable to the program.  
 
We looked at the file and Medicare rules. Specifically, we find that the provider numbers for the origin 
hospital, and destination hospital, are different. Based on this information, we decided that Medicare rules for 
coverage of the non-emergency ambulance transportation and ground mileage have been met. Therefore, we 
decided that the Plan has to pay for the non-emergency ambulance transportation (A0426) and ground mileage 
(A0425) provided on March 2, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialist office visits provided on July 13, 2022, to 
August 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visits. You say that you broke your hand, and your nurse 
practitioner referred you to the provider. The Plan denied your request. The Plan says the rendering provider is 
an OON provider, and the Plan denied the referral to the OON provider on July 29, 2022, because there were 
in-network providers available. 
 
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 specialist office visits provided on July 13, 
2022, to August 3, 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 genetic testing provided on June 14, 2021, billed with 
codes 81401, 81225, 81227, 81226, 81230, 81231, 81240, 81241, 81291, 81328, 81335, and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that the codes were correctly billed with 
payable diagnosis codes. The Plan denied your request. The Plan says panel testing should be billed using one 
Current Procedural Terminology (CPT) code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 14, 2021, billed with codes 81401, 81225, 81227, 81226, 81230, 81231, 81240, 81241, 81291, 81328, 
81335, and 81355.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 9, 2022, to 
February 7, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the required 
data element, admission/start of care date on the subsequent period of care claim does not match the admission 
date reported on the first period of care NOA claim. Therefore, we decided that the Plan does not have to pay 
for the home health services provided from January 9, 2022, to February 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on 
February 23, 2022, and February 24, 2022. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
denial should be overturned in its entirety and payment approved for the original billed DRG 444. The Plan 
denied your request. The Plan says the DRG was reported improperly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 444. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that given the enrollee was status post cholecystectomy with a normal magnetic resonance 
cholangiopancreatography (MRCP), the records did not support the use of DRG 444 in this case. The records 
did not support the use of diagnosis code of calculus of gallbladder without cholecystitis with obstruction in 
this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee on February 23, 2022, and February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, a therapeutic, prophylactic, or diagnostic 
injection, and a ketorolac injection provided on June 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit, a therapeutic, prophylactic, or diagnostic injection, and a 
ketorolac injection. You say that the registration staff and the member were not informed that there should be 
an authorization prior to the visit. The Plan denied your request. The Plan says the rendering provider is a non-
participating provider. The Plan also says there is no referring provider involved in these services. The Plan 
also says they did not authorize any services for this provider. 
 
  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, a therapeutic, prophylactic, or 
diagnostic injection, and a ketorolac injection provided on June 17, 2022, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an appointment and labs provided on March 31, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an appointment and labs. You say that this should be covered, the patient needed 
these services. The Plan denied your request. The Plan says there was no preauthorization by a primary care 
provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 appointment and labs provided on March 31, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on March 8, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed 
based on the submitted documentation. The Plan denied your request. The Plan says the criteria for coverage 
have not been satisfied. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
provided on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shipping fee provided on June 25, 2022. 
 You asked the Plan to pay for the shipping fee. You say that your benefit has a $250 allowance for optical 
hardware which is covered in full. The Plan denied your request. The Plan says the shipping fee is not a 
covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover these services. 
 
We looked at the file and the Plan's rules. Specifically, the shipping fee is not a covered service. Specifically, 
the Plan paid $119.90 towards the eyeglasses.  Based on this information, we decided that the Plan's rules for 
coverage of the shipping fee have not been met. Therefore, we decided that the Plan does not have to pay for 
the shipping fee provided on June 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse an out-of-network specialist visit with labs provided on 
June 27, 2022. 
 
You asked the Plan to reimburse an out-of-network specialist visit with labs. You say that you would like your 
full refund otherwise you will change providers. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for physician/practitioner services, including doctor's office visits. The total allowed amount for this 
case is $198.41. Therefore, the claim was processed and paid correctly in the amount of $183.41 after a payable 
copayment amount of $15.00. 
 
You have been asked to pay a $183.41 total copayment for an out-of-network specialist visit with labs. This 
item/service 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 reimburse an out-of-network specialist visit with labs provided on June 
27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays on May 24, 2022. 
 
You asked the Plan to waive the copayment for x-rays. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for each basic imaging service (e.g., general x-rays or ultrasound). Covered services include, but are 
not limited to X-rays. 
 
You have been asked to pay a $20 copayment for x-rays. This item/service 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 x-rays on May 24, 2022.