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

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 
12, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you were seen to remove stitches 
from a previous surgery and that you were told there would be no charge for the removal of stitches. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. The Plan says the surgical 
procedure codes you previously received do not include follow-up days. The removal of stitches is a stand-
alone service and therefore, the visit is subject to a specialist 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 a $40 
copayment for each Medicare-covered specialist visit.  
 
You have been asked to pay a $40 copayment for a specialist visit. This service falls within the 
physician/practitioner services, including doctors 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 waive the copayment for a specialist office visit provided on August 12, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on  
May 31, 2022. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these items are not payable as they were 
purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid vendor.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the hearing aids in this case were not purchased from 
the Plans select hearing aid vendor. The Plan contract states that hearing aids purchased outside of the Plans 
hearing network are not covered. Therefore, we decided that the Plan does not have to issue reimbursement for 
the hearing aids (V5261) purchased on May 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 35 miles of routine transportation services. 
 
You asked the Plan to pre-approve an additional 35 miles of routine transportation services. You say that it is 
necessary for you to receive additional miles of routine transportation. The Plan denied your request. The Plan 
says the requested transportation exceeds the Plan's benefit limit for routine transportation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the one-way distance is not to exceed 50 miles.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the requested 
location exceeds the covered 50 miles of driving distance. Therefore, we decided that the Plan does not have to 
pre-approve an additional 35 miles of routine transportation services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GeneSight Pharmacogenomic (PGx) testing (81479). You asked the Plan to pre-approve GeneSight testing. You say that this test is medically necessary as the 
enrollee has been on several different medications which have been ineffective. The Plan denied your request. 
The Plan says the criteria for PGx testing are not met in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve GeneSight testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is suffering from Bipolar Disorder Unspecified, Anxiety Disorder 
Unspecified, Posttraumatic Stress Disorder, Unspecified and Attention Deficit Hyperactivity Disorder, 
Combined Type, which does mean that the enrollee has a condition which meets the Medicare coverage criteria 
for the GeneSight Psychotropic Assay. The documentation shows that the enrollee has not responded to at least 
one medication which is noted in the record as well as being on multiple medications for which there was a 
documented failure of response. However, it does not appear that the criteria for this test are met as the enrollee 
has been inconsistent in taking these medications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of GeneSight testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve GeneSight Pharmacogenomic (PGx) testing (81479).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker (E0149) and a seat attachment 
(E0156). 
 
You asked the Plan to pre-approve a heavy-duty walker and a seat attachment. You say that you need the 
walker in order to walk. You were operated on your left knee but now have pain in your right knee. You do not 
have transportation and you need to move around by taking the bus. The Plan denied your request. The Plan 
says you do not meet coverage criteria for approval of the heavy-duty walker. You do not weigh over 300 
pounds. You were also previously issued a walker in 2020. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker is covered for beneficiaries 
who meet coverage criteria for a standard walker and who weigh more than 300 pounds. 
 
We looked at the file and Medicare rules. Your records show that you weigh 160 pounds. The records also 
show that you were approved and issued a walker on September 25, 2020. The EOC confirms that DME 
supplies are limited to equipment and devices which do not duplicate the function of another piece of 
equipment or device covered by the Plan. Based on this information, we decided that Medicare rules for 
coverage of a heavy-duty walker and a seat attachment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a heavy-duty walker (E0149) and a seat attachment (E0156).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for and office visit and pathology services provided on October 
19, 2021, and November 1, 2021, by an OON provider. 
 
You asked the Plan to pay for and office visit and pathology services. You say that you disagree with the denial 
and would like the Plan to reconsider payment. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
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 and office visit and pathology services provided 
on October 19, 2021, and November 1, 2021, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on February 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an ultrasound. You say that you are classified as silent providers and are not 
liable or have the authority to obtain authorizations and/or take the necessary measures to ensure medical 
criteria are met for patients by the facility. The Plan denied your request. The Plan says the enrollee must 
receive care from a network 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 ultrasound provided on February 25, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a denosumab injection and a specialist office 
visit provided on May 24, 2022. 
 
You asked the Plan to waive the cost share for a denosumab injection and a specialist office visit. You say that 
you are on a fixed income and this cost share amount is untenable. 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 20% 
coinsurance for Medicare Part B non-chemotherapy prescription drugs. Your contract with the Plan also clearly 
says that you must pay a $45 copayment for each covered visit or consultation in an outpatient location with a 
specialist.  
 You have been asked to pay $255.12 for a denosumab injection ($1,275.60 x 20% = $255.12). You have also 
been asked to pay $45 for a specialist office visit. The total you owe is $300.12 ($255.12 + $45 = $300.12). 
The denosumab injection falls within the for Medicare Part B prescription drugs benefit category. The 
specialist office visit falls within the Physician/Practitioner services, including doctors 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 waive the cost share for a denosumab injection and a specialist office 
visit provided on May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0651) and 
appliance (E0668) provided from June 23, 2022, to July 2, 2022. 
 
You asked the Plan to pay for that PCD and appliance. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items that are used for a preventative service or 
function are excluded from coverage under the Medicare DME benefit.  
 We looked at the file and Medicare rules. Per A52488, the requested PCD is not covered, as it was requested 
for preventive purposes. As the requested PCD is not covered, the appliance (E0668) is also not covered. Based 
on this information, we decided that Medicare rules for coverage of that PCD and appliance have not been met. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0651) 
and appliance (E0668) provided from June 23, 2022, to July 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee on April 25, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that these services were rendered in good faith and 
medically necessary. The Plan denied your request. The Plan says that services from non-participating 
providers are not covered under the plan unless they are authorized before the services are provided. 
 
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 medical services provided to the enrollee on 
April 25, 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 laboratory services coded 81479 provided on April 15, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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. 
 
 We find that CPT code 81479 is not supported in the medical record. Specifically, this code was billed with GZ 
modifier. This means this code is not payable as billed. 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 the laboratory services coded 81479 provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hormone replacement therapy provided on June 28, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for hormone replacement therapy. You say that you have been under this provider's 
care for 15 years and that you should have been notified years ago to get a prior approval authorization. The 
Plan denied your request. The Plan says you must receive your car from a network 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 hormone replacement therapy provided on June 
28, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for surgical repair of a hip fracture after fall.  Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve C4-5, C5-6, C6-7 anterior cervical disc fusion. 
 
You asked the Plan to pre-approve the spinal procedure. The Plan denied your request. The Plan says this 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 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 spinal procedure. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the imaging studies do not show severe nerve root or cord compression at these levels. 
Also, there is no spinal instability. 
 
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 spinal procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve C4-5, C5-6, C6-7 anterior cervical disc fusion.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan on April 
27, 2022. 
 
You asked the Plan to waive the copayment for CT. 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 $150 
copayment for radiological diagnostic service if performed at outpatient hospital. Covered services include but 
are not limited to other outpatient diagnostic tests  Radiological diagnostic services, not including x-rays. 
Examples include specialized scans, CT, SPECT, PET, MRI, MRA, nuclear studies, or ultrasounds. The 
provider billed in the amount of $2,106 and the allowed amount is $124.75. This is less than the copayment 
amount. Therefore, resutls in the total cost sharing amount of $124.75. 
 
 
 You have been asked to pay a $124.75 copayment, which is less than the copayment for CT. 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 computed tomography (CT) scan on April 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were admitted for encephalopathy and stroke. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.