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

 
We decided that the Plan does not have to pay for PET scan provided on April 06, 2023. 
 
You asked the Plan to pay for PET scan. You say that you are asking for the review of the attached information 
and medical records. 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 PET scan provided on 
April 06, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on March 11, 2023. 
 
You asked the Plan to pay for the radiology 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 the radiology services 
provided on March 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on May 13, 2023, to 
May 18, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you say that there shouldn't 
be any responsibility 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 $300 
copayment each day for days 1-6, for each Medicare-covered inpatient hospital stay. Includes inpatient acute, 
inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient 
hospital care starts the day you are formally admitted to the hospital with a doctors order. The day before you 
are discharged is your last inpatient day. There were five days. 5 x $300 = $1,500. Therefore, results in the total 
cost sharing amount of $1,500. 
 
You have been asked to pay a $300 copayment each day for inpatient hospital stay. This item/service falls 
within the inpatient hospital 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 
inpatient hospital stay on May 13, 2023, to May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 87633 billed for date of service February 20, 2023.

You asked the Plan to pay for procedure code 87633. You say that you disagree with the denial. The Plan denied your request. The Plan says payment for code 87633 is bundled into payment for code 87502.

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 87633 is a column II code to column I code 87502. This claim has not been billed with an appropriate modifier to bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 87633 billed for date of service February 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs provided on January 
06, 2023, to January 20, 2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs. You say that the cost share applied is 
incorrect. 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 drugs. 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. The total coinsurance you owe is $1,721.81, which is 20% of the allowed 
amount for Medicare Part B chemotherapy drugs ($8,609.06 allowed x 20% = $1,721.81). Therefore, we 
decided that the Plan does not have to waive the coinsurance for chemotherapy drugs provided on January 06, 
2023, to January 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
April 23, 2023, to April 29, 2023. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not understand 
why you are 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 $225 
copayment per day, for days 1 to 5 and a $0 copayment per day, for additional Medicare-covered days for an 
inpatient stay. 
 You have been asked to pay a $225 copayment per day, for days 1 to 5 of the inpatient hospital stay. You have 
been asked to pay a total of $1,125 ($225 copayment x 5 days = $1,125). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital 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 an inpatient hospital stay provided from April 23, 2023, to April 29, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital stay provided on April 14, 2023, to 
April 21, 2023. 
 
You asked the Plan to pay for an inpatient hospital stay. 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 an inpatient hospital stay 
provided on April 14, 2023, to April 21, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on April 13, 
2023. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that you were told that you did not 
need a referral. 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 psychiatric diagnostic 
evaluation provided on April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and related services provided on May 16, 
2023. 
 
You asked the Plan to pay for an office visit, and related services. You say that you do not feel that you should 
have to change providers. 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, and 
related services provided on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 11, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was 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 the office visit provided on April 11, 2023, by an 
OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve greater saphenous vein (GSV) ablation and 
sclerotherapy. 
 
You asked the Plan to pre-approve the sclerotherapy. You say that the enrollee has several incompetent 
varicose veins in the thigh and calf. You say that you believe these are responsible for the enrollee's refractory 
dependent edema and aching pain. You say that the enrollee has attempted over 20 weeks of conservative 
management with no significant improvement of symptoms. You also say that the enrollee's swelling impacts 
their activities of daily living. The Plan denied your request. The Plan says this service is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are at least 
4 millimeters (mm) in diameter and if the patient remains symptomatic after a six-week trial of conservative 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the sclerotherapy. Our reviewer says 
that the requested sclerotherapy is not medically necessary. Our physician reviewer found for tributary 
treatment such as sclerotherapy to be considered medically necessary per coverage criteria, there needs to be 
persistent significant symptoms following successful treatment of truncal (saphenous) reflux with these 
symptoms existing more than 6 weeks after the reflux was treated and despite conservative efforts. As the 
enrollee has not yet undergone saphenous vein reflux treatment, the above criteria have not been met. The 
health plan does not provide for simultaneous saphenous reflux treatment and tributary treatment. A rationale 
for this is that many patients experience satisfactory relief with the truncal intervention alone. Therefore, the 
reviewer found that the requested sclerotherapy is 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 the sclerotherapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve greater saphenous vein (GSV) ablation and sclerotherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on April 20, 2023. 
 
You asked the Plan to pay for a home visit evaluation. 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 home visit evaluation 
provided on April 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, advanced life support, non-emergency 
transport and ground mileage provided on April 12, 2023. 
 You asked the Plan to pay for the ambulance services and ground mileage. You say that the enrollee required 
transportation to a different hospital for a higher level of care. The Plan denied your request. The Plan says 
claims history indicates the enrollee was in an inpatient hospital status. 
 
The Plan must follow Medicare rules. Medicare rules say that that once a beneficiary is admitted to a hospital it 
may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care 
while the beneficiary maintains inpatient status with the original provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services and ground mileage have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance service, advanced life support, non-emergency transport and ground 
mileage provided on April 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital stay provided on August 28, 2022, to 
August 31, 2022. 
 
You asked the Plan to pay for an inpatient hospital stay. 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 an inpatient hospital stay 
provided on August 28, 2022, to August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation (D0364) provided 
on January 26, 2022. 
 
You asked the Plan to pay for cone beam CT. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 pay for cone 
beam CT capture and interpretation (D0364) provided on January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81455, 81194 and 81301 billed for date of 
service November 22, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please review and reprocess this claim as 
soon as possible The Plan denied your request. The Plan says payment for codes 81194 and 81301 is bundled 
into procedure code 81455.  In addition, the submitted molecular pathology code was not submitted with the 
required DEX Z-code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that for molecular diagnostic tests, 
such as the test at issue, the MolDX program requires these tests to be reviewed to determine whether Medicare 
reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique 
identifier and the coverage status is listed in the DEX Diagnostics Exchange. 
 
Review of the claim does not show that the required unique identifier was reported. We have also confirmed 
that codes 81194 and 81301 are column II codes to column I code 81455. 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 codes 81455, 81194 and 
81301 billed for date of service November 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the heavy metal testing of selenium and zinc assays (84255, 
84630) provided April 5, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you request for review of the medical 
records and process claim for payment. The Plan denied your request. The Plan says this service does not meet 
the coverage requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There is no documentation provided by the provider of any detailed 
medical history, including documentation of occupational and avocational exposure to these toxins, and records 
do not document a complete physical examination. Based on this information, we decided that Medicare rules 
for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to 
pay for the heavy metal testing of selenium and zinc assays (84255, 84630) provided April 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the below knee flex cover system (L5962). 
  
You asked the Plan to pre-approve the below knee flex cover system (L5962). You say that you need assistance 
in approving the requested services so you can continue to live a good quality of life. The Plan denied your 
request. The Plan says the request does not meet criteria for medical necessity. 
 
The Plan follows Medicare rules. Medicare rules say that protective outer surface covering systems (L5962, 
L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. They are used by a 
beneficiary who has special needs for protection against unusually harsh environmental situations where it is 
necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704, L5705, 
L5706, and L5707. They are not for cosmetic or convenience reasons, or for everyday usage in a typical 
environment. 
 
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 prosthetic leg. Our reviewer says that 
the item is not medically necessary. Our physician reviewer found given the specific documentation 
requirements for this component, it is incumbent on the certified prosthetist/orthotist (CPO) to provide a 
medical record that meets these requirements. However, in this case, no such justification or context is found in 
the record (neither from the CPO nor primary care provider (PCP) clinic notes) to suggest that your prosthesis 
will be exposed to unusually harsh environments necessitating additional protection beyond what is provided 
with a typical cover (e.g., L5704, which has already been approved by the Plan).  
 
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 below knee flex cover system has not been met. Therefore, we decided that 
the Plan does not have to pre-approve the below knee flex cover system (L5962).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on April 18, 2023. 
 
You asked the Plan to waive the copayment for the eye exam. 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 $45 
copayment for vision care.  

You have been asked to pay a $45 copayment for the eye exam. This service falls 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 the eye exam provided on April 18, 2023.