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

 
We decided that the Plan does not have to pay for removal of impacted cerumen provided on September 11, 
2023. 
 
You asked the Plan to pay for removal of impacted cerumen. You say that the services at issue were a medical 
necessity for the enrollee. 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 removal of impacted 
cerumen provided on September 11, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance treatment services provided 
on August 29, 2023. 
 
You asked the Plan to waive the copayment for the ambulance treatment services. You say that you should not 
be held responsible for this service. 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 $270 
copayment for ambulance services. 
 
You have been asked to pay a $270 copayment for the ambulance treatment services. This item/service falls 
within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance treatment services provided on August 29, 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 
August 30, 2023. 
 
You asked the Plan to waive the copayment for a new patient office visit. You say that this service should be 
covered. 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 in-network provider and professional services provided in a specialists office. 
 
You have been asked to pay a $45 copayment for a new patient office visit. This item/service falls within the 
in-network provider and professional services provided in a specialists office 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 August 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the genetic testing provided on June 22, 
2023. 
 
You asked the Plan to waive the coinsurance for the genetic testing. You say that you disagree with the 
coinsurance. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for the genetic testing. 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. The total amount you owe is $720 ($3,600 allowed 
amount x 20% = $720). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
genetic testing provided on June 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 22, 2023. 
 
You asked the Plan to pay for the laboratory services. 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 the laboratory services 
provided on July 22, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement provided on July 06, 2023. 
 
You asked the Plan to pay for the nail debridement. 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 the nail debridement 
provided on July 06, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency department visit provided on 
September 15, 2023. 
 
You asked the Plan to waive the copayment for an emergency department visit. You say that you were released 
from the hospital prematurely following outpatient surgery. 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 $95 
copayment for in and out-of-network emergency care. 
 
You have been asked to pay a $95 copayment for an emergency department visit. This item/service falls within 
the in and out-of-network emergency 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 emergency department visit provided on September 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral surgery services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve oral surgery services. You say that the requested referral is medically 
necessary. The Plan denied your request. The Plan says you have not sought care with an in-network oral 
surgeon. 
 
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 
oral surgery services to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-pneumatic compression device.  
 
You asked the Plan to pre-approve the requested device. You say that it is felt that this is necessary to treat the 
enrollee's condition. The Plan denied your request. The Plan says a pneumatic compression device is available 
from network providers. 
 
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 the requested device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found future studies are needed to directly compare the safety and efficacy of non-
pneumatic compression devices to a traditional pneumatic compression device for the treatment of lower 
extremity lymphedema.  
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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the non-pneumatic compression device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95800 billed for date of service June 9, 2023. 
 
You asked the Plan to pay for procedure code 95800. You say that this service was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was not submitted with 
a diagnosis which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 95800. Any codes which are not listed are considered not medically necessary for 
code 95800. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 95800 have not been met. Specifically, this claim was submitted with a diagnosis 
code which is not among those codes listed as medically necessary and appropriate for this service. Therefore, 
we decided that the Plan does not have to pay for procedure code 95800 billed for date of service June 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cane (E0105), a wheelchair seat cushion (E2619), a walker 
(E0143) and durable medical equipment, miscellaneous (E1399) provided on August 21, 2023. 
 
You asked the Plan to pay for durable medical equipment. You say that you would like to be reimbursed 50% 
of the claim because you received these items from an out-of-network provider. The Plan denied your request. 
The Plan says the items you obtained were rendered by a provider who is not under contract with the health 
plan and is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a cane (E0105), a wheelchair seat 
cushion (E2619), a walker (E0143) and durable medical equipment, miscellaneous (E1399) provided on 
August 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the criteria for an IRF admission, 
and their needs cannot be met at a lower level of care. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, but skilled therapies as an outpatient or at a skilled nursing facility (SNF) 
may be approved upon request.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this patient will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI), 
brain provided on August 27, 2023. 
 
You asked the Plan to waive the copayment for the magnetic resonance imaging (MRI), brain. You say that 
you do not agree with the billed amount for your MRI. 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 $350 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $350 copayment for the magnetic resonance imaging (MRI), brain. 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 the magnetic resonance imaging (MRI), brain provided on 
August 27, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy system (E0691) provided on 
August 18, 2023. 
 
You asked the Plan to pay for the ultraviolet light therapy. You say that you would like this claim to be 
reprocessed. The Plan denied your request. The Plan says this request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ultraviolet cabinets are covered for selected patients 
with generalized intractable psoriasis. 
 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 the ultraviolet light therapy. Our reviewer 
says that the ultraviolet light therapy system (E0691) was not medically necessary. Our physician reviewer 
found the patient was noted to have pruritus due to bed bug bites. The patient was prescribed a steroid cream 
and educated to have their home evaluated for extermination of the bed bugs. Our reviewer found that an 
ultraviolet light therapy system is not medically indicated for the treatment of bed bug bites. Our physician 
reviewer also found that the patient does not have psoriasis or psoriasis that has failed to respond to 
conservative treatment measures. 
 
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 ultraviolet light therapy have not been met. Therefore, we decided that the 
Plan does not have to pay for the ultraviolet light therapy system (E0691) provided on August 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination (x-ray) of the chest (71045) 
provided on July 1, 2023. 
 
You asked the Plan to pay for the x-ray. You say that the service was billed correctly and should be paid. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 4, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the x-ray have not been met. Therefore, we 
decided that the Plan does not have to pay for the radiologic examination (x-ray) of the chest (71045) provided 
on July 1, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs rendered on August 24, 2023, to 
August 27, 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 self-administered drugs 
rendered on August 24, 2023, to August 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the inpatient hospital stay provided from 
August 17, 2023, to August 19, 2023. 
 
You asked the Plan to waive the deductible for the inpatient hospital stay. You say that the enrollee was in the 
emergency department and was not admitted inpatient. 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 $300 deductible which applies to inpatient hospital care.  
 
 
 
 The record shows you had met your maximum out-of-pocket amount during this stay. You have been asked to 
pay $300, which satisfied the deductible for the inpatient hospital stay. The item or service you asked the Plan 
to waive the deductible for falls within the inpatient hospital care benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $300 deductible which applies to inpatient 
hospital care. This cost sharing is a contractual obligation that had not been met at the time the inpatient 
hospital stay was received on August 17, 2023, to August 19, 2023. Therefore, we decided that the Plan does 
not have to waive the deductible for the inpatient hospital stay provided from August 17, 2023, to August 19, 
2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for oncology (solid organ), targeted genomic sequence analysis, formalin-
fixed paraffin-embedded (FFPE) tumor tissue, DNA analysis, 84 or more genes (0334U) performed on June 30, 
2023. 
 
You asked the Plan to pay for the DNA analysis, 84 or more genes. You say that the services were billed 
correctly. The Plan denied your request. The Plan says that the documentation does not support the services as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 the DNA analysis, 84 or more genes. Our reviewer says that 
the services are supported. Our reviewer found the coding is correct, as per coding guidelines 0334U is used 
only for Guardant 360 tissue next for guardant health inc, which is the processer of this lab. Requirements were 
met for the analysis of 84 or more genes for genetic mutation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the DNA analysis, 84 or more genes have been met. Therefore, we decided that 
the Plan has to pay for oncology (solid organ), targeted genomic sequence analysis, formalin-fixed paraffin-
embedded (FFPE) tumor tissue, DNA analysis, 84 or more genes (0334U) performed on June 30, 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.