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

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on February 14, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that this should be paid by the plan. 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). Your contract with the Plan clearly says that you must pay $130 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
 
 
 You have been asked to pay $108.71 which is less than the standard $130 copayment for an ultrasound. an 
ultrasound 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 an ultrasound provided on February 14, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 19, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says services from non-
par providers are not covered under an HMO plan unless preauthorized. 
 
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 
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 psychotherapy provided on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne Heme (81455) provided November 18, 2022 
 
You asked the Plan to pay for the laboratory services. You say that the documentation included with your 
appeal provides all of the applicable information needed to adequately consider your appeal. The Plan denied 
your request. The Plan says this test is not covered by Medicare and is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. 81455 is a group 3 code and is not covered. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for FoundationOne Heme (81455) provided 
November 18, 2022
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on July 30, 2021. 
 
You asked the Plan to pay for critical care. You say that this service was billed appropriately. The Plan denied 
your request. The Plan says this service is not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported. Specifically, the time spent providing this service is not noted 
in the medical record. Without this information, we cannot verify if 30-74 minutes of critical care were 
provided on the date in question. Based on this information, we decided that Medicare rules for coverage of 
critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first 
hour (99291) provided on July 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device 
provided on September 27, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a continuous positive airway pressure (CPAP) device. You say that you would 
like to request reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-
network and authorization is required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) 
device provided on September 27, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 16, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 physician's services provided on February 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 6, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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 have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 28, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, lenses, and miscellaneous vision item or service 
provided on September 7, 2021 by an out-of-network (OON) provider. 
 You asked the Plan to pay for the frames, lenses, and miscellaneous vision item or service. You say that you 
were told by a Plan representative that the facility you went to was in-network. You also say that you are on a 
fixed income and have no extra income. The Plan denied your request. The Plan says there are no call records 
that indicate you were given the facility you were treated by as an in-network provider. The Plan also says that 
services provided by OON providers are 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. The Plan covers these services when they are obtained from a provider in the Plans vision vendor 
network. 
 
We looked at the file and the Plan's rules. The record shows these services were rendered by an OON provider. 
Based on this information, we decided that the Plan's rules for coverage of the frames, lenses, and 
miscellaneous vision item or service have not been met. Therefore, we decided that the Plan does not have to 
pay for the frames, lenses, and miscellaneous vision item or service provided on September 7, 2021 by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity prosthesis with Flex-walk system and 
multi-axial rotation unit (a K3 foot). 
 
You asked the Plan to pre-approve the requested prosthesis. You say that this item is medically necessary. The 
Plan denied your request. The Plan says this specific item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that additional options for a lower limb prosthesis are 
only coverable if 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 requested prosthesis. Our reviewer 
says that the requested prosthesis with K3 foot is not medically necessary. Our physician reviewer found there 
is no documentation that the K3 foot at issue in this case meets Medicare criteria for medically reasonable and 
necessary. Provided medical records from the enrollee's treating physician do not document a K3 functional 
level or a need for the K3 foot requested.  
 
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 prosthesis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lower extremity prosthesis with Flex-walk system and multi-axial rotation unit 
(a K3 foot).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 10 additional PT visits. You say that you need these additional visits 
because you do not have the same equipment at home that the facility provides. The Plan denied your request. 
The Plan says you do not meet criteria for continued therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 10 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found 10 additional PT visits are not medically necessary.  The 
doctor says that you appear to have made some improvement with therapy after 91 physical therapy treatments, 
but given the chronic progressive nature of your disease, further improvement in your functional status does not 
appear to be predictable in a reasonable time frame to necessitate further skilled therapy services. Transition to 
a home exercise program appears appropriate at this point.  
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the computed tomography (CT) scan of the 
face you had on February 14, 2022. 
 
You asked the Plan to reduce the copayment for the CT scan. You say that you believe your copayment for this 
service should only be $30. The Plan denied your request. The Plan says you were charged this cost sharing 
correctly. The Plan says that because the allowed amount for this CT scan ($118.44) is less than your 
copayment obligation, you are responsible for the full allowed 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 $125 
copayment for radiological diagnostic services (not including x-rays).  
 
You have been asked to pay a $125 copayment for the CT scan. The CT scan falls within the radiological 
diagnostic 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 reduce the copayment for the computed 
tomography (CT) scan of the face you had on February 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services at the Diagnosis Related Group 
(DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
diagnosis is supported in the medical record. The Plan denied your request. The Plan says the principal 
diagnosis of A41.9 (sepsis, unspecified organism) is not supported in the medical record. 
 
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 principal diagnosis of A41.9 (sepsis, unspecified 
organism). 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 a principal diagnosis of A41.9 (sepsis, unspecified organism) is 
not supported in the medical record. Our physician reviewer found that the documentation indicates that the 
patients vital signs in the emergency room demonstrated temperature of 98.1, heart rate of 95, respiratory rate 
of 20, blood pressure of 121/41, and SpO2 95% on room air. Laboratory values demonstrated a white blood 
cell count of 19.3, lactic acid level 1.1 mmol/L, platelet count of 341K, creatinine level of 0.5 mg/dL, and urine 
culture was positive for E. Coli. Documentation of a P/F ratio less than 400 based on an arterial blood gas, 
platelet count less than 150, 000, total bilirubin level greater than 1.2 mg/dL, creatinine level greater than 1.2 
mg/dL, or Glasgow Coma Score less than 15 were not found in the record. The patient is noted to have a 
history of dementia per the record and no baseline mental status was noted by providers. Per the provider notes, 
the patient's mental status was "alert awake oriented times 3". Arterial blood gas values and total bilirubin 
levels were not noted in the record. Urine output volumes were not consistently documented in the record as 
the patient was noted as incontinent per nursing. Urine volumes and unmeasured urine occurrences were noted 
in the flow sheets. Documentation of acute oliguria or anuria by providers was not found in the record. Blood 
cultures demonstrated no growth after 5 days. No sequential organ failure criteria points were met based on the 
submitted medical record.  
 
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 at the Diagnosis Related Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing rendered on November 1, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that FANCC genetic testing is non-covered. 
 
We looked at the file and Medicare rules. The testing at issue is FANCC genetic testing. Therefore, we decided 
that the Plan does not have to pay for the FANCC genetic testing rendered on November 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care (99233) provided on February 7, 
2022. 
 
You asked the Plan to pay for the inpatient care. You say that the enrollee was not enrolled in hospice on the 
date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 5, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the inpatient hospital 
care (99233) provided on February 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Nebulizer on December 20, 2020. 
 
You asked the Plan to waive the coinsurance for Nebulizer. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost-sharing 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 20% 
coinsurance for Medicare-covered durable medical equipment (DME).  Covered items include, but are not 
limited to: wheelchairs, crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a 
provider for use in the home, IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, 
and walkers. The provider billed in the amount of $50.73 and the approved amount is $12.17. $12.17 x 20% = 
$2.43. Therefore, resulting in the total cost-sharing amount of $2.43.  
 
 
 You have been asked to pay a 20% coinsurance for Nebulizer. Nebulizers fall within the Durable medical 
equipment (DME) and related 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 Nebulizer on December 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nonemergency transport services in a wheelchair van, 6 
round trips. 
 
You asked the Plan to pre-approve transportation services. You say that the enrollee has a medical need for 
transport with a wheelchair van due to their decreased mobility. You say that the enrollee is not able to get in 
and out of a car, facilitating the need for a transport van with wheelchair accessibility. The Plan denied your 
request. The Plan says transport by a wheelchair van is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve nonemergency transport services in a wheelchair van, 6 
round trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testosterone. 
 
You asked the Plan to pre-approve Testosterone. The Plan denied your request. The Plan says Testosterone to 
be administered at home is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Testosterone.  
 
 
 Benefits for Testosterone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 23, 2022. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says services 
from non-participating providers are not covered unless preauthorized. 
 
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 
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 ambulance services provided on February 23, 2022.