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

 
We decided that the Plan does not have to pay for an office visit provided on December 30, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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 December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided on March 28, 2023. 
 
You asked the Plan to pay for a psychotherapy visit. You say that you and the provider were not aware a 
referral was needed. 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 psychotherapy visit 
provided on March 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gauze, impregnated with other than water, normal 
saline, or hydrogel, sterile, pad size more than 16 sq in but less than or equal to 48 sq in, without adhesive 
border, each dressing (A6223 x10), gauze, nonimpregnated, nonsterile, pad size 16 sq in or less, without 
adhesive border, each dressing (A6216), and foam dressing, wound cover, sterile, pad size 16 sq in or less, with 
any size adhesive border, each dressing (A6212x10). 
 
You asked the Plan to pre-approve wound care supplies. 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 follows Medicare rules. Medicare rules say that surgical dressings are covered when a qualifying 
wound is present. 
 
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 wound care supplies. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found recent encounters described you as 
having dressing changes but no debridement procedures and that it was healing and even healed as early as July 
2, 2023. Therefore, as you had not received surgical debridement of the wound, you do not meet coverage 
criteria for these wound supplies at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wound care supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad 
size more than 16 sq in but less than or equal to 48 sq in, without adhesive border, each dressing (A6223 x10), 
gauze, nonimpregnated, nonsterile, pad size 16 sq in or less, without adhesive border, each dressing (A6216), 
and foam dressing, wound cover, sterile, pad size 16 sq in or less, with any size adhesive border, each dressing 
(A6212x10).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 10, 2023, to January 13, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $440 
copayment per day, for days 1 to 4 and a $0 copayment per day, for days 5 to 90 for each Medicare-covered 
hospital stay.  
 
 You have been asked to pay a $440 copayment per day, for days 1 to 3 of the inpatient hospital stay. You have 
been asked to pay a total of $1,320 ($440 copayment x 3 days = $1,320). 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 the inpatient hospital stay provided from January 10, 2023, to 
January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 20, 2023. 
 
You asked the Plan to pay for home health services. You say that 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 home health services 
provided on January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skin removal procedure provided on February 08, 2023. 
 
You asked the Plan to pay for a skin removal procedure. You say that this was medically necessary and should 
be covered. 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 skin removal 
procedure provided on February 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network hearing test provided on 
January 05, 2023. 
 
You asked the Plan to waive the copayment for an in-network hearing test. You say that you already paid at the 
doctors office, you do not understand why you have to pay a second time. 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 hearing services. 
 
You have been asked to pay a $40 copayment for an in-network hearing test. This item/service falls within the 
hearing 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 an in-network 
hearing test provided on January 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 7, 2022, by an OON 
provider.  
 
You asked the Plan to pay for an office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that this 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 an office visit provided on June 7, 2022, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on January 27, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that the assisted living facility is responsible 
to obtain prior authorization for all 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 home visit for 
evaluation provided on January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye exam provided on October 27, 2022. 
 
You asked the Plan to pay for a medical eye exam. You say that the provider was not responsible for obtaining 
authorization. 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 medical eye exam 
provided on October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluation provided on March 07, 
2023. 
 
You asked the Plan to pay for psychiatric diagnostic evaluation. You say that the services should be covered. 
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 psychiatric diagnostic 
evaluation provided on March 07, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI), brain with contrast 
provided on September 20, 2022. 
 
You asked the Plan to pay for magnetic resonance imaging (MRI), brain with contrast. 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 magnetic resonance 
imaging (MRI), brain with contrast provided on September 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on January 24, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
refused treatment, and you did not need assistance due to the condition you have. You also say that you do not 
owe $500, nor can you afford it. The Plan denied your request. The Plan says the ambulance was called, and 
you were not transported to an emergency facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 24, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on January 24, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve placement of the Micra leadless pacemaker. 
 
You asked the Plan to pre-approve the leadless pacemaker. You say that this is a medically necessary 
treatment.  The Plan denied your request. The Plan says that Medicare only covers this service when the patient 
is enrolled in a Coverage with Evidence Developement (CED) study. It was confirmed that the enrollee is not 
going to be part of such a study.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided a valid denial rationale in this case. The Plan has 
indicated that the sole reason for denial is that there is no evidence of participation in a CED study. It is noted 
that the treating provider was contacted and confirmed that they do not participate in clinical trials. One type of 
CED study that allows coverage would be a clinical trial into which a patient would be prospectively enrolled.  
 
However, there are several other observational studies as well as a Food and Drug Administration (FDA) post-
approval study which also meet the requirements of CED. These observational studies/registries do not require 
prospective enrollment. The enrollment is automatic upon submission of a claim for a leadless pacemaker. As 
such, we find that the denial based solely on lack of study participation is not appropriate as once the 
pacemaker is placed, enrollment would occur.  Therefore, we decided that the Plan has to pre-approve 
placement of the Micra leadless pacemaker.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 23, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 provided on December 29, 2022. 
 
You asked the Plan to pay for procedure code G0482. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code G0482 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the record supports that 
only three drug classes were tested, including Benzodiazepines, Opiates, and Oxycodone. Based on this 
information, we decided that Medicare rules for coverage of procedure code G0482 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code G0482 provided on December 29, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on February 18, 2023. 
 
You asked the Plan to pay for the emergency room services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says your facility is not a valid Medicare 
provider and you have provided no evidence that you can bill Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, licensed independent freestanding 
emergency departments (EDs) cannot bill Medicare. However, during the COVID-19 Public Health Emergency, these providers can become temporary Medicare providers if they meet certain criteria. 
 
In this case, there is no evidence that your facility meets any of the criteria listed above in order to receive 
Medicare payment. There is no evidence that your facility is affiliated with a hospital, and you have provided 
no evidence that you have completed the temporary enrollment process to become a Medicare hospital. As a 
result, payment to your facility cannot be made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ED services have not been met. Therefore, we decided that the Plan does not have to pay for 
the emergency room services provided on February 18, 2023.