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

 
We decided that the Plan does not have to waive the copayment for radiation therapy (G6015) provided on 
March 15, 2022. 
 
You asked the Plan to waive the copayment for radiation therapy. You say that you were not aware of this 
copayment and cannot afford it. The Plan denied your request. The Plan says this processed 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 $60 
copayment for therapeutic radiological services.  
 
You have been asked to pay a $60 copayment for radiation therapy. Radiation therapy falls within the 
therapeutic radiological services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
radiation therapy (G6015) provided on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the services should be covered as you disagree 
with the denial and would prefer to see the same provider. The Plan denied your request. The Plan says the 
services denied correctly as they are non-emergent and can be provided in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided 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 provided on October 20, 2021. 
 
You asked the Plan to pay for the laboratory 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 supported. 
 
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 the laboratory services provided on October 20, 2021, have been met. In this case, medical records were requested multiple times by the Plan with 
no response. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81161, 81286, 81413, 81414, 81442, 
81479) provided on October 21, 2021. 
 
You asked the Plan to pay for laboratory services. You say that the provider is certified, and this was billed 
correctly. The Plan denied your request. The Plan says records to support these services were not received. 
 
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 laboratory services (81161, 81286, 
81413, 81414, 81442, 81479) provided on October 21, 2021. have been met. Medical records documenting the 
billed services have not been submitted. The records show that the Plan made several requests for these 
records. Therefore, we decided that the Plan does not have to pay for laboratory services (81161, 81286, 81413, 
81414, 81442, 81479) provided on October 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this service is medically necessary. The 
Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital or the skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. 
 
 
 
 
 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 21, 2022. 
 
You asked the Plan to pay for the laboratory 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 supported. 
 The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on January 21, 2022.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to waive the copayments for electroconvulsive therapy (ECT) treatment provided 
from January 26, 2022, to May 18, 2022. 
 
You asked the Plan to waive the copayments for the ECT treatment. You say that other claims for the same 
treatment had no copayments. The Plan denied your request. The Plan says that you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan does not say in clear and accurate terms 
how much you should expect to pay for electroconvulsive therapy (ECT) treatment.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $150 
copayment per visit for the ECT treatment. The Plan contract does not clearly say how much enrollees must 
pay for these services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing 
information. Therefore, we decided that the Plan has to waive the copayments for electroconvulsive therapy 
(ECT) treatment provided from January 26, 2022, to May 18, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve molecular pathology testing of the CDKN2A gene. 
 
You asked the Plan to pre-approve the CDKN2A gene testing. You say that you believe that this testing should 
be approved because you have digestive issues that this testing could explain. The Plan denied your request. 
The Plan says this is not covered for your condition. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
 A test is considered screening when it is provided in the absence of signs/symptoms of illness or injury. In this 
case, the genetic test at issue is used to determine the presence of inherited cancer-causing mutations. However, 
the records do not show that the enrollee has any signs or symptoms suggestive of cancer. The documentation 
supports that this testing is requested due to a family history alone of breast cancer and melanoma. This would 
be considered screening testing which is excluded from Medicare coverage. Therefore, we decided that the 
Plan does not have to pre-approve molecular pathology testing of the CDKN2A gene.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision services provided on May 3, 2022. 
 
You asked the Plan to waive the copayment for vision services. The Plan denied your request. The Plan says 
the claim paid with the correct allowable amount, which is less than the copayment 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 $30 
copayment for Vision Care.  
 
 
 
 
 
 
 
 
 You have been asked to pay the allowed amount of a $29.47 copayment for vision services. The vision services 
fall within the Vision Care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for vision 
services provided on May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oncology office visit with an out-of-network (OON) 
provider using the in-network benefit level. 
 
You asked the Plan to pre-approve the oncology office visit. You say that you saw this provider years ago and 
would like to continue your treatment with them. The Plan denied your request. The Plan says the requested 
provider is an OON provider, and the provider does not accept the Plan's insurance despite the enrollee's PPO 
plan. Also, a list of in-network provider has been given to the enrollee that provide the same quality of service. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees may choose to receive care from out-of-network providers using the Plans Preferred 
Provider Organization (PPO) benefits. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services at an in-network benefit level. Therefore, we decided that the Plan 
does not have to pre-approve an oncology office visit with an out-of-network (OON) provider using the in-
network benefit level.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom shoes (L3219) and custom orthotics (L3030). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the items at issue do not meet Medicare criteria for 
coverage. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not meet Medicare criteria for coverage of the requested orthopedic footwear. 
Specifically, the type of orthopedic inserts requested are only covered when they are an integral part of a 
covered brace and medically necessary for the proper functioning of that brace. Additionally, the custom shoes 
requested in this case are denied by Medicare as non-covered.  Therefore, you do not meet criteria for coverage of these items. Therefore, we decided that the Plan does not 
have to pre-approve custom shoes (L3219) and custom orthotics (L3030).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 17, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the services billed. 
 
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 the laboratory services provided on 
December 17, 2021, have been met. The Plan made multiple attempts to obtain supporting medical records from the provider without success. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on December 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 26, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 April 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 29, 2021. 
 
You asked the Plan to pay for the laboratory 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 supported. 
 The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (G0483) provided September 7, 2021. 
 
You asked the Plan to pay for the lab testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 G0483 is not supported in the medical record. Specifically, only lab results were 
provided. No clinical records were submitted for review to support the service and no physician order for the 
lab procedures was submitted. Based on this information, we decided that Medicare rules for coverage of the 
lab testing have not been met. Therefore, we decided that the Plan does not have to pay for lab testing (G0483) 
provided September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided on January 
9, 2022. 
 
You asked the Plan to pay for the CGM. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the enrollee does not meet criteria for the provided 
CGM. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the 
CGM have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose 
monitor (CGM) provided on January 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the rendering and referring providers are both nonparticipating with the 
Plan. The Plan also says that these services 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 an office visit provided on March 25, 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 outpatient clinic visit provided on May 20, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient clinic visit. You say that it was medically necessary to treat the 
enrollee and you would like the claim paid. The Plan denied your request. The Plan says the rendering provider 
is an OON provider and there was no referral from an in-network provider or an approved authorization. Also, 
the service rendered was 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 the outpatient clinic visit provided on May 20, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous fixation device (zip). 
 
You asked the Plan to pre-approve an interspinous fixation device (zip). You say that an interspinous fixation 
device (zip) is medically necessary. The Plan denied your request. The Plan says an interspinous fixation 
device (zip) is experimental/investigational. 
 
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 an interspinous fixation device (zip). 
Our reviewer says that an interspinous fixation device (zip) is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that this is considered experimental/ investigational device 
as two learned orthopedic societies have not endorsed its use. Therefore, the request is considered not 
medically reasonable or 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 an interspinous fixation device (zip) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous fixation device (zip).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 29, 2021. 
 
You asked the Plan to pay for the medical services. You say that the patient gave you incorrect insurance 
information.  As soon as you received corrected information, you submitted this claim. The Plan denied your 
request. The Plan says this claim was not timely filed. 
 
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 the medical services was not filed until May 5, 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 medical services provided on March 29, 2021.