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

 
We decided that the Plan does not have to pay for microbiology procedures, infectious agent antigen detection 
(CPT 87633) provided on February 13, 2021. 
 
You asked the Plan to pay for microbiology procedures, infectious agent antigen detection. The Plan denied 
your request. The Plan says Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. 
The pathogen targets that compose the panels are determined by the manufacturers that make them, and do not 
represent specific pathogens that cause a common syndrome, or the organisms that commonly are found in a 
specific sample type or patient population or reflect seasonal variations. The fixed nature of these multiplex 
panels includes pathogens that cause infections different enough that simultaneous testing for these pathogens 
should be rare. This is not a COVID-19 test. This is not an emergency test. 
 
The Plan follows Medicare rules. Medicare rules say that the following is considered not medically reasonable 
and necessary: Panels with >5 respiratory pathogens performed in the Part B outpatient setting. 
 
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 microbiology procedures, infectious agent 
antigen detection. Our reviewer says that microbiology procedures, infectious agent antigen detection is not 
medically necessary. Our physician reviewer found based upon a review of the documentation submitted, this 
enrollee with past medical history of Z03.818, Encounter for observation for suspected exposure to other 
biological agents ruled out, J02.9 Acute pharyngitis, unspecified, R51.9 Headache, unspecified, R05 Cough, 
Z71.89 Other specified counseling received CPT Code 87633/QW Infectious agent detection by nucleic acid 
(DNA or RNA); respiratory virus (e.g., adenovirus, influenza virus, coronavirus, metapneumovirus, 
parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when 
performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets. The review has 
determined that the requested microbiology procedures, infectious agent antigen detection does not meet the 
Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of microbiology procedures, infectious agent antigen detection have not been met. 
Therefore, we decided that the Plan does not have to pay for microbiology procedures, infectious agent antigen 
detection (CPT 87633) provided on February 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) and supplies provided 
on February 25, 2022, by an OON provider. 
 
You asked the Plan to pay for the DME and supplies. You say that you were unable to obtain an authorization 
and the hospital is the one who dispensed the equipment. 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 durable medical equipment (DME) and 
supplies provided on February 25, 2022, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for LTACH care have 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 there is no documentation provided indicating medical necessity for LTACH 
services. The enrollee is receiving appropriate care at the present acute care hospital. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on December 15, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that you have received the services by 
the same doctor for over 5 years and the plan has always made the payments. The Plan denied your request. 
The Plan says you have been charged the correct 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 each Medicare-covered visit.  
 
You have been asked to pay $21.63, which is less than the $30 copayment for an office visit. The office visit 
falls within the Podiatry 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 
an office visit provided on December 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the outpatient mental health visit provided 
on January 21, 2022. 
 
You asked the Plan to waive the deductible for an outpatient mental health visit. You say that you would like to 
pay your $30 copayment and be done with it. The Plan denied your request. The Plan says you have only met 
$126.22 of your $300 deductible so far this year. Once you have met your $300 deductible then you will be 
responsible for a $30 copayment for each Medicare-covered individual outpatient mental health visit. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan clearly says that there is a $300 combined in-network and out-of-network deductible that 
applies outpatient mental health visits.   
 
 The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Mental Health Care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$300 deductible that applies to outpatient mental health visits. This cost sharing is a contractual obligation that 
had not been met at the time an outpatient mental health visit was received on January 21, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible for an outpatient mental health visit provided on 
January 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility services from 
January 1, 2022 to January 28, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility services. You say that you were 
receiving medication intravenously via pic line under doctor's orders. You asked the facility, as did my wife to 
release me with the pic line installed. The Plan denied your request. The Plan says you have been charged the 
correct 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 $0 
copayment for each day(s) 1-20, and $188 for each day(s) 21-100 in a network skilled nursing facility.  
 
 
 
 You have been asked to pay a total of $1316 for skilled nursing facility ($188/day x 7 = $1316). Skilled nursing 
facility fall within the Skilled nursing facility (SNF) 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 skilled nursing facility services from January 1, 2022 to January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on December 1, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the outpatient services. You say that you would like the claim to be reprocessed 
for payment. 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 services provided on December 1, 
2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and an excision, benign lesion including 
margins, except skin tag (unless listed elsewhere) provided on September 14, 2021, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an office visit and an excision, bening lesion including margins, except skin tag 
(unless listed elsewhere). You say that the claim was denied for support of documentation, and the physician 
reviewed the records and amended his records to reflect, in more detail, the service provided. The Plan denied 
your request. The Plan says the services are not authorized because this provider is a non-network provider 
who does not work with the Plan, and the member was referred by a provider who also does not work with the member's Plan. The Plan also says that the physician did not refer for services, and alternate network providers 
were found. 
 
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 and an excision, benign lesion 
including margins, except skin tag (unless listed elsewhere) provided on September 14, 2021, by an out-of-
network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ambulance transportation provided on 
June 12, 2021. 
 
You asked the Plan to waive the coinsurance for the ambulance transportation. You say that you should be fully 
covered for the ambulance ride. The Plan denied your request. The Plan says the proper coinsurance was 
applied for the service that was rendered. 
 
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 each one-way Medicare-covered ground trip. The first total amount allowed was $470.33 with 
a coinsurance of $94.07 ($470.33 total amount allowed x 20% coinsurance). The second total amount allowed 
was $15.26 with a coinsurance of $3.05 ($15.26 total amount allowed x 20% coinsurance). The total 
coinsurance amount for the service provided was $97.12 ($94.07 coinsurance + $3.05 coinsurance). You have been asked to pay a $94.07 coinsurance for the ambulance transportation. The ambulance 
transportation falls within the Ambulance 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 
coinsurance for the ambulance transportation provided on June 12, 2021.  
 
Your complaint about your experience with this provider is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740), core build up (D2950), and scaling and 
root planing (D4341 x 4) provided on November 12, 2021, by the out of network provider. 
 
You asked the Plan to pay for the dental services. You say that you made an appointment with a provider that 
your husband had had a good experience with. You say that you tried to get an appointment with 2 other 
dentists before you did this. You also say that no one had appointments available for 3 months. The Plan denied 
your request. The Plan says dental services received out of network are not covered. The Plan also says that 
you were advised prior to your visit that the provider did not accept your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the crown (D2740), core build up (D2950), and scaling and root planing (D4341 x 4) provided on November 
12, 2021, by the out of network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ultrasound evaluation provided on September 15, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Ultrasound evaluation. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Ultrasound evaluation provided on September 15, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for treatment room services provided on 
November 24, 2021. 
 
You asked the Plan to waive the copayment for treatment room services. You say that you want to know why 
you were charged for the treatment room. The Plan denied your request. The Plan says the copayment that was 
applied was only for the allowed amount and not the standard $275 copayment for outpatient surgery services. 
 
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 $275 
copayment for outpatient surgery services for the treatment room used for your surgical nail procedure. 
 
 
  You have only been asked to pay $50.96 instead of the standard $275 copayment for treatment room services 
for your surgical nail procedure. Treatment room services falls within the Outpatient hospital 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 treatment room services provided on November 
24, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Duplex scan provided on May 26, 2021. 
 
You asked the Plan to waive the copayment for Duplex scan. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the copayment applied was 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 $135 
copayment for Duplex scan. The allowed amount of the claim is $123.79 
 
You have been asked to pay a $135 copayment for Duplex scan. Duplex scan 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 Duplex scan provided on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 9, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sends the specimen to 
your laboratory, and you would like the claim to be paid. The Plan denied your request. The Plan says the 
referring and rendering providers are both OON providers and there was no 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 laboratory services provided on December 9, 
2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
December 6, 2021. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that you were not told 
ahead of time that you would have to pay a $45 copayment for a telephone conversation, and you do not think 
that you should have to pay such a copayment. The Plan denied your request. The Plan says you were 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 clearly says that you must pay a $45 
copayment for physician specialist services (including telehealth services).  
 
You have been asked to pay a $45 copayment for a specialist telehealth visit. A specialist telehealth 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 telehealth visit provided on December 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Computerized tomography (CT) scan provided on October 
22, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Computerized tomography (CT) scan. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Computerized tomography (CT) scan provided on 
October 22, 2021 by an out-of-network (OON) provider.