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

 
We decided that the Plan does not have to waive the copayment for an in-network laboratory draw provided on 
May 11, 2023. 
 
You asked the Plan to waive the copayment for an in-network laboratory draw. You say that you did not have 
an appointment on this day, you were never there. 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 $40 
copayment for lab services only when provided in an outpatient hospital facility. 
 
You have been asked to pay a $40 copayment for an in-network laboratory draw. This item/service falls within 
the lab services only when provided in an outpatient 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 copayment for an in-network laboratory draw provided on May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit provided on May 04, 2023. 
 
You asked the Plan to pay for the telehealth visit. 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 telehealth visit 
provided on May 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each physical therapy service provided on 
March 09, 2023, to March 30, 2023. 
 
You asked the Plan to reduce the copayment for each physical therapy service. You say that you think that the 
copayment should be lower. 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 $40 
copayment for in-network physical therapy services provided at an outpatient hospital. 
 
You have been asked to pay a $40 copayment for each physical therapy service. This item/service falls within 
the in-network physical therapy services provided at an outpatient hospital 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 amount you owe is $365 ($40 
copayment x 9 services = $360). The Plan is only holding you responsible for a $5 copayment for services 
rendered on March 21, 2023. Therefore, we decided that the Plan does not have to reduce the copayment for 
each physical therapy service provided on March 09, 2023, to March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 12 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 12 months. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 a ventilator for 12 months. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has 
chronic obstructive pulmonary disease (COPD) and chronic respiratory failure and was prescribed bilevel 
positive airway pressure (BIPAP), with failure of compliance on multiple occasions. Changing the mode of 
ventilator will not improve compliance, hence a home ventilator likely will not be used as well. A home 
ventilator is not indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator for 12 months have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a ventilator for 12 months (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 13, 2023. 
 
You asked the Plan to pay for the home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. 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 home visit provided 
on March 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 19, 2022 to 
February 17, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 19, 2022 to 
February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 21, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services rendered 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 an office visit provided 
on April 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network laboratory draw provided on 
May 01, 2023. 
 
You asked the Plan to waive the copayment for an in-network laboratory draw. You say that you have these 
test done because you have a heart condition. 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 $64.95 
copayment for Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $64.95 copayment for an in-network laboratory draw. This item/service 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 an in-network laboratory draw provided on May 01, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each ambulance service provided on April 
26, 2023, to April 28, 2023. 
 
You asked the Plan to waive the copayment for each ambulance service. You say that you are in no position to 
pay these bills. 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 $200 
copayment for one-way ambulance trips. 
 
You have been asked to pay a $200 copayment for each ambulance service. This item/service falls within the 
one-way ambulance trips 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 amount you owe is $400 ($200 copayment x 2 services = $400). Therefore, we 
decided that the Plan does not have to waive the copayment for each ambulance service provided on April 26, 
2023, to April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on April 
03, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not be charged 
for a physician follow-up. 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 $15 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for a specialist 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. However, you have been asked to pay less than the 
standard copayment, you only owe $10. Therefore, we decided that the Plan does not have to waive the 
copayment for a specialist office visit provided on April 03, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided August 22, 2022 to August 
24, 2022. 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 22, 2022. The NOA was not received by the Plan until October 3, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
August 22, 2022 to August 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 provided from April 15, 2023, to 
April 17, 2023. 
 
You asked the Plan to pay for procedure code 99233. You say that the medical records support the billing of 
code 99233.  The Plan denied your request. The Plan says the medical records do not support the billing of 
code 99233.  
 
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, the CPT Code Manual definition of code 99233 is Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 We asked our coder 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 procedure code 99233. Our reviewer says that the medical 
records do not support the billing of code 99233.  Our reviewer found the notes do not support this level of 
billing for any of the service dates. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 provided from April 15, 2023, to April 17, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a cardiovascular stress test provided on 
April 17, 2023. 
 
You asked the Plan to reduce the copayment for a cardiovascular stress test. You say that you were told this 
was an in-network provider. 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 $175 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $175 copayment for a cardiovascular stress test. This item/service falls within the in-network 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 reduce the copayment for a cardiovascular stress test provided on April 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Part B drugs and vision services on February 
14, 2023, to March 30, 2023.  
 
You asked the Plan to waive the cost share for Part B drugs and vision services. You say that you are not able 
to take on anymore expenses during these times. 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 each Medicare-covered Part B drug and non-chemotherapy drugs to treat cancer. Covered 
drugs include drugs that usually arent self-administered by the patient and are injected or infused while you 
are getting physician, hospital outpatient, or ambulatory surgical center services. You must pay a $15 
copayment for each Medicare-covered exam for vision services. Covered services include outpatient physician 
services provided by an ophthalmologist or optometrist for the diagnosis and treatment of diseases and injuries 
of the eye, including diagnosis or treatment for age-related macular degeneration or cataracts. Original 
Medicare doesnt cover routine eye exams (eye refractions) for Your provider may need to eyeglasses/contacts. 
The provider billed in the amount of $2,200 and the allowed amount is $1,905.34 for the service. $1,905.34 x 
20% = $381.07. The provider also billed a $15 copayment. $381.07 + $15 = $396.07. There were two dates of 
service. 2 x $396.07 = $792.14. Therefore, results in the total cost sharing amount of $792.14. 
 
You have been asked to pay a 20% coinsurance for each Part B drug and a $15 copayment for each vision 
service. This item/service falls within the Medicare Part B prescription drugs and vision 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 Part B drugs and vision services on February 14, 
2023, to March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nonpneumatic compression controller with sequential 
calibrated gradient pressure (K1024) and a nonpneumatic sequential compression garment, full leg (K1032). 
 
You asked the Plan to pre-approve a nonpneumatic compression controller and garment. You say that you 
request reconsideration and have attached medical records for review. The Plan denied your request. The Plan 
says there is insufficient evidence in the medical literature to demonstrate that the Koya Dayspring Active 
Compression Garment System is an effective treatment modality for the treatment of lymphedema. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a nonpneumatic compression controller 
and garment. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested device is a nonpneumatic sequential 
compression garment with sequential calibrated gradient pressure that is used for the treatment of lymphedema. 
The requested device has not been shown to be superior to other standard treatments for the medical condition. 
The studies do not indicate the Koya Dayspring Active Compression Garment System improves an enrollee's 
function or general health compared to standard treatment. The requested device is not medically 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 a nonpneumatic compression controller and garment have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a nonpneumatic compression controller with 
sequential calibrated gradient pressure (K1024) and a nonpneumatic sequential compression garment, full leg 
(K1032).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genomic testing provided on May 24, 2023. 
 
You asked the Plan to pay for genomic testing. You say that this testing was 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 genomic testing 
provided on May 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on March 30, 2023, billed with codes 
87481, 87500, 87640, 87641, 87653, & 87798. 
 
You asked the Plan to pay for the lab testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the lab testing billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing provided on March 
30, 2023, billed with codes 87481, 87500, 87640, 87641, 87653, & 87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on February 23, 2023. 
 
You asked the Plan to pay for a drug test. 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 drug test provided on 
February 23, 2023.