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

 
We decided that the Plan does not have to waive the cost share for an injection and a specialist visit provided 
on July 26, 2023. 
 
You asked the Plan to waive the cost share for an injection and a specialist visit. You say that you disagree with 
the cost share applied. 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 prescription drugs and a $40 copayment for each specialist visit.  
 You have been asked to pay $278.49 for an injection and a specialist visit. This total includes $264 
coinsurance, which is 20% of the allowed amount for a Medicare Part B drug injection ($1,320 allowed x 20% 
= $264) and a $14.49 copayment, which is less than the standard amount for a specialist visit. The injection 
falls within the Medicare Part B prescription drugs benefit category. The specialist visit falls within the 
physician/practitioner 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 cost share for an 
injection and a specialist visit provided on July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3310/D3320), and crowns 
(D2740). 
 
You asked the Plan to pre-approve the dental services. You say that you need this root canal. The Plan denied 
your request. The Plan says the denied dental services are not covered benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
endodontic therapy (D3310/D3320), and crowns (D2740).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, arthrocentesis, and the triamcinolone 
injection provided on May 10, 2023, by an OON provider.  
 
You asked the Plan to pay for the office visit, arthrocentesis, and injection. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says these services are not covered 
when received by an out-of-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 a POS option to use either network providers or out-of-network providers for certain 
covered services. Certain covered services may only be received from network providers. The Plan contract 
also says that out-of-network Medicare Part B drugs, outpatient surgery services, and physician services are not 
covered. 
 
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 
items/services 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 office visit, arthrocentesis, and the 
triamcinolone injection provided on May 10, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total electric hospital bed with any type side rails, with 
mattress (E0265, E1399). 
 
You asked the Plan to pre-approve the hospital bed . You say that a fully electric hospital bed is medically 
necessary to assist with the enrollee mobility and independence. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve total electric hospital 
bed with any type side rails, with mattress (E0265, E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GIAnomics Oncology Germline Panel provided on June 
30, 2023. 
 You asked the Plan to pay for the GIAnomics Oncology Germline Panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says screening tests are not covered. 
 
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. 
 
The test at issue in this appeal, the GIAnomics Oncology Germline Panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the GIAnomics Oncology Germline Panel provided on June 30, 2023.
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 the services are medically necessary. The 
Plan denied your request. The Plan says your medical needs are being met in the current setting. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for your diagnosis and condition. 
 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 pay for an office visit provided on August 03, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services were medially necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 03, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral doxycycline rendered on May 1, 2023. 
 
You asked the Plan to pay for the medication. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 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 pay for the oral doxycycline rendered on 
May 1, 2023.  
 
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities provided on August 17, 2023. 
 
You asked the Plan to pay for therapeutic activities. You say that the enrollee was referred by their primary 
care provider (PCP). The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for therapeutic activities 
provided on August 17, 2023.
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 the enrollee was admitted into the 
hospital on November 11, 2023 for an infection and was on 2 antibiotics. You also say that she has a folate that 
had blood in it and also has a wound that is getting more severe. The Plan denied your request. The Plan says  
the enrollee is receiving appropriate in-patient acute care and does not require transfer to a long term acute care 
hospital. 
 
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 at the time of the request for LTACH the enrollee's status is stable.  The enrollee does not require services at the LTACH that are not available at the acute care hospital where she 
is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and are 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy treatment provided on 
August 04, 2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy treatment. You say that you disagree with the 
cost share applied and would like the amount charged to be reconsidered. 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 prescription drugs. 
 
You have been asked to pay 20% coinsurance for chemotherapy treatment. This item/service falls within the 
Medicare Part B prescription drugs 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. You have been asked to pay $1,016.51, which is 20% of the allowed amount for 
Medicare Part B chemotherapy drugs. Therefore, we decided that the Plan does not have to waive the 
coinsurance for chemotherapy treatment provided on August 04, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 6, 2023, through 
June 12, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the documentation indicates a reasonable belief that, at the time of admission, two midnights of care 
would be required to further evaluate and treat the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from June 6, 2023, through June 12, 2023.  
 
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 pay for the laboratory services billed with codes 87481, 87640, 
87651, 87653, and 87798 for May 31, 2023. 
 
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 multiplex tests must be billed with only one testing 
code. 
 
We looked at the file and Medicare rules. The file shows that the panel was not billed with one single testing 
code. 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 billed with codes 
87481, 87640, 87651, 87653, and 87798 for May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration in conjunction with periradicular surgery (D3431). 
 
You asked the Plan to pre-approve D3431. You say that this is all part of a root canal. The Plan denied your 
request. The Plan says this is not a covered dental benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery 
(D3431).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit and the laboratory services 
provided on June 07, 2023. 
 
You asked the Plan to pay for a hospital outpatient clinic visit and the laboratory services. You say that you are 
requesting reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a hospital outpatient 
clinic visit and the laboratory services provided on June 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion pump and supplies described by codes E0781, 
A4221, and A4222 billed for date of service May 15, 2023. 
 You asked the Plan to pay for E0781, A4221, and A4222. You say that that E0781, A4221, and A4222 should 
be paid as billed because they are supported in the medical record. The Plan denied your request. The Plan says 
code E0781 is denied because payment for this service is included in payment for code 96413, which was 
billed on the same date. A4222 and A4221 are denied because they have a medically unlikely edit value of 0, 
so they are not separately reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for the administration of a drug or 
biological billed to the MAC will also include payment for the equipment used in furnishing the service. 
Equipment that the enrollee takes home to complete an infusion is not separately billable as durable medical 
equipment. 
 
We looked at the file and Medicare rules. The provided records indicate that on May 15, 2023, infusion of the 
drug 5-Fluoracil was started in the care setting, and the enrollee was then sent home with an infusion pump and 
supplies coded as E0781, A4221, and A4222 to continue the infusion and return to the care setting for a pump 
disconnect on a later date. Per MLN Matters Article SE1609, the equipment, such as an external infusion pump 
and accompanying supplies, used in furnishing the infusion service is not separately billable as durable medical 
equipment when the drug or biologic is billed to the MAC, as is the case in this instance. Based on this 
information, we decided that Medicare rules for coverage of E0781, A4221, and A4222 have not been met. 
Therefore, we decided that the Plan does not have to pay for the infusion pump and supplies described by codes 
E0781, A4221, and A4222 billed for date of service May 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87640, 87481 and 87798) provided on 
March 21, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this panel was not reported in accordance with 
Medicare billing guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory panel (87640, 87481 and 87798) provided on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the discharge management services 
provided on May 26, 2023. 
 
You asked the Plan to reduce the cost share for the discharge management services. You say that you thought 
that you would only have a $50 copayment. 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. Your 
contract with the Plan says that there is a $150 deductible which applies to outpatient hospital services. Your 
contract with the Plan also clearly says that you must pay 10% coinsurance after the deductible for hospital 
services. 
 
 You have been asked to pay $79.66, which satisfied the deductible for the discharge management services. The 
remaining allowed amount is $33.57 $113.23 allowed amount - $79.66 deductible = $33.57). The item or 
service you asked the Plan to reduce the cost share for falls within the outpatient hospital services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 
deductible which applies to outpatient hospital services. This cost sharing is a contractual obligation that had 
not been met at the time the discharge management services was received on May 26, 2023.  
 
You have been also asked to pay $3.35, which is 10% coinsurance of the remaining allowed amount for the 
discharge management services ($33.57 remaining allowed amount x 10% = $3.35). This item/service falls 
within the outpatient hospital services benefit category. You have been asked to pay a total of $83.01 ($79.66 
deductible + $3.35 coinsurance = $83.01). 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 cost share for the 
discharge management services provided on May 26, 2023.