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

 
We decided that the Plan does not have to pay for the laboratory services provided October 31, 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 claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. 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 DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided October 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an in-network an in-network Medicare Part B 
injectables provided from May 22, 2023, to May 24, 2023. 
 
You asked the Plan to waive the cost for an in-network an in-network Medicare Part B injectables. You say that 
you were told you would only have a $50 copayment. This is a much higher amount than you could ever 
afford, and this will cause a hardship. 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 20% 
coinsurance for Medicare Part B prescription drugs, and a $40 copayment for services performed at a hospital 
facility.  The allowed amount of this drug is $16,805, resulting in a coinsurance amount of $427.74 ($16,805 x 20% = 
$427.74). You had two sets of injections, resulting in a $855.48 total coinsurance ($427.74 x 2 = $855.48 + $40 
copayment = $895.48). 
 
You have been asked to pay a $895.48 coinsurance for and in-network Medicare Part B injectables. This 
item/service falls within the Medicare Part B prescription drugs and services performed at a hospital facility 
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 for an in-network an in-network Medicare 
Part B injectables provided from May 22, 2023, to May 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on April 29, 2023. 
 
You asked the Plan to pay for drug testing. You say that this is supported in the 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 drug testing provided on 
April 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an infusion provided on January 20, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an infusion. You say that you are requesting reconsideration for the service 
provided. The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives 
from an out-of-network provider (a provider who is not part of the plans network) will not be 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 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 infusion provided on January 20, 2023, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Maverick Vertical Shock foot (L5986, L5987). 
 
You asked the Plan to pre-approve Maverick Vertical Shock foot. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria are met. 
 
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 Maverick Vertical Shock foot. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the certified 
prosthetist/orthotist's (CPOs) notes from August, including an amputee mobility predictor without prosthesis 
(AMP-noPRO) score demonstrating K3 level, is corroborated by the surgeons notes from July and August of 
this year. These more than satisfy Medicare requirements for documenting his K3 functional potential as well 
as your particular need for the new prosthetic foot in question. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Maverick Vertical Shock foot have been met. Therefore, we decided that the 
Plan has to pre-approve Maverick Vertical Shock foot (L5986, L5987).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) scan; thorax provided on April 
13, 2023. 
 
You asked the Plan to pay for computed tomography (CT) scan; thorax. You say that you are appealing the 
claim payment denial. 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 computed tomography 
(CT) scan; thorax provided on April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasonic guidance for needle placement, and related 
services provided on March 30, 2023. 
 
You asked the Plan to pay for ultrasonic guidance for needle placement, and related services. You say that 
these services were medically 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 ultrasonic guidance for 
needle placement, and related services provided on March 30, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for not otherwise classified drugs provided on March 15, 2023. 
 
You asked the Plan to pay for not otherwise classified drugs. You say that the claim was denied in error. 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 not otherwise classified 
drugs provided on March 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on May 31, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you should 
not be responsible for the cost share since the hospital does not have any record of the procedure or test results. 
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 $250 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $250 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests 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 you owe is $247.48, which is less than the standard copayment for 
an MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance 
imaging (MRI) provided on May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667) to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compression device and an appliance. You say that the enrollee 
suffers of chronic lymphedema. The enrollee needs to start the compression therapy to reduce and maintain this 
lifetime condition, as well as to avoid future infections and ulcers. The Plan denied your request. The Plan says 
the enrollee must receive services from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
a pneumatic compression device (E0651) and a segmental pneumatic appliance for use with pneumatic 
compressor, full leg (E0667) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 20, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you don't agree with the denial. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of the plans network) will not be 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 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 20, 2023, by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air ambulance transport (A0430). 
 
You asked the Plan to pre-approve an air ambulance transport. You say that the enrollee's health is declining at 
a steady pace, and he wants to be home before it gets worst. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for an air ambulance. 
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance transport. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has 
respiratory failure, pneumonia, and congestive heart failure (CHF) who was recently started on home oxygen 
was transported from his daughter's home in Ohio after a recent hospitalization to the enrollee's home in 
Maryland. A request was made for air ambulance to the enrollee's home. However, the provided notes 
described the enrollee as stable on his home oxygen, not requiring ambulance services at the time of this 
request. The documentation does not support that the enrollee suffers from an illness or injury that 
contraindicates transportation by any means other than ambulance. The documentation also does not support 
that the enrollee's condition was such that the time needed to transport an enrollee by ground, or the instability 
of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's 
health. 
 
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 air ambulance transport have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an air ambulance transport (A0430).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an interrogation device evaluation 
provided on January 30, 2023. 
 
You asked the Plan to waive the coinsurance for an interrogation device evaluation. You say that you have 
never had to pay for anything concerning your pacemaker. 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 other Medicare-covered outpatient services. 
 
You have been asked to pay 20% coinsurance for an interrogation device evaluation. This item/service falls 
within the other Medicare-covered outpatient 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. The total you owe is $6.65 ($33.25 allowed amount x 20% = 
$6.65). Therefore, we decided that the Plan does not have to waive the coinsurance for an interrogation device 
evaluation provided on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for meditation provided from November 1, 2022, to January 1, 
2023. 
 
You asked the Plan to pay for meditation. You say that this should be covered as meditation sessions are 
considered a wellness program. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a wellness 
allowance which includes participation in instructional fitness classes, participation in online instructional 
fitness classes or membership fees for online fitness subscriptions, membership in a qualified health club or 
fitness facility, visits to a licensed acupuncturist, and visits to a licensed nutritional counselor or registered 
dietician for nutritional counseling services. 
 
 The Plans rules for coverage of gym benefits have not been met because The Plan rules say they cover a 
wellness allowance which includes participation in instructional fitness classes, participation in online 
instructional fitness classes or membership fees for online fitness subscriptions, membership in a qualified 
health club or fitness facility, visits to a licensed acupuncturist, and visits to a licensed nutritional counselor or 
registered dietician for nutritional counseling services. Meditation is not a part of this benefit. Therefore, we 
decided that the Plan does not have to pay for meditation provided from November 1, 2022, to January 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a new patient office visit provided on 
March 28, 2023. 
 
You asked the Plan to waive the copayment for a new patient office visit. You say that you do not think you 
should have to pay. 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 $30 
copayment for in and out-of-network consultation, diagnosis, and treatment by a specialist. 
 
You have been asked to pay a $30 copayment for a new patient office visit. This item/service falls within the in 
and out-of-network consultation, diagnosis, and treatment by a specialist 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 new patient office visit provided on March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on April 25, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for home visit evaluation. You say that you are requesting reconsideration for the 
service provided. The Plan denied your request. The Plan says the enrollee must receive their care from a 
network provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee 
receives from an out-of-network provider (a provider who is not part of the plans network) will not be 
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 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 home visit for evaluation provided on April 25, 
2023, 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 an office visit provided on April 12, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for an office visit. This item/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 an office visit provided on April 12, 2023.