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

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy provided from March 27, 
2020 to April 24, 2020. 
 
You asked the Plan to waive the coinsurance for chemotherapy. You say that you were not made aware of any 
cost sharing. The Plan denied your request. The Plan says the coinsurance you are being charged is correct. 
 
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 chemotherapy prescription drugs.  
 
You have been asked to pay a $988.32 coinsurance for chemotherapy on March 27, 2020 and a $988.32 
coinsurance for chemotherapy on April 10, 2020, which is 20% of the allowed amount of $4941.60 for each 
date of service. You have also been asked to pay a $213.36 coinsurance for chemotherapy on April 24, 2020, 
which is less than 20% of the allowed amount of $4941.60. This comes to a total of $2190 ($988.32 + $988.32 
+ $213.36).  
 
Chemotherapy falls within the Medicare Part B prescription drugs benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for chemotherapy provided from March 27, 2020 to April 24, 2020.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that IRF level of intensive therapy exceeds your need. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. You 
are medically stable after a stroke with no evidence of need for supervision by physical medicine and rehab 
physician or need for acute rehab nursing care. Functionally given your current level, you do not require IRF 
level of therapies. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do 
not require an intensive therapy program. IRF admission is not medically necessary based on your current 
functional status and lack of medical complexity. Our physician reviewer found that your condition does not 
meet Medicare criteria for IRF care. 
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 6, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
services provided on December 6, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 28, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says  
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for a CT scan provided by an in-network provider on 
June 2, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that since this was a follow-up you 
shouldn't have to pay for this., The Plan denied your request. The Plan says that the correct copayment has been 
applied. 
 
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 enrollees must pay a $175 copayment for outpatient diagnostic tests/diagnostic 
imaging.  
 
The Plan says you must pay a $175 copayment for a CT scan. Information was not provided to show that the 
correct copayment was applied. Therefore, we decided that the Plan has to waive the copayment for a CT scan 
provided by an in-network provider on June 2, 2020.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vascular ultrasound provided by a 
participating provider on April 6, 2020. 
 
You asked the Plan to waive the copayment for vascular ultrasound. You say that you do not agree with this 
copayment. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $25 
copayment for outpatient diagnostic tests/carotid or peripheral vascular ultrasound.  
 
You have been asked to pay a $25 copayment for vascular ultrasound. Vascular ultrasound falls within the 
outpatient diagnostic tests/carotid or peripheral vascular ultrasound 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 vascular ultrasound provided by a participating provider on April 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a myelography and a CT scan provided on 
March 10, 2020. 
 
You asked the Plan to waive the copayments for a myelography and a CT scan. You say that you feel that you 
should only owe $200. The Plan denied your request. The Plan says the claims were processed correctly, and 
you are being charged the correct amount. 
 
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 outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. Your contract with the Plan also clearly says that you must pay a $200 copayment for CT 
scans.  
 
You received a myelography on March 10, 2020. A myelography is considered an outpatient surgical 
procedure. Therefore, you are responsible to pay the $200 copayment.  
 
You received a CT scan on March 10, 2020. Therefore, you are responsible to pay the $200 copayment.  
 
The total amount you owe is: $400.  
 
You have been asked to pay the total copayment amount of $400 for a myelography and a CT scan. A 
myelography and a CT scan fall within the outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers 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 copayments for a myelography and a CT 
scan provided on March 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the application of a multi-layer 
compression system provided from February 24, 2020 to March 23, 2020. 
 
You asked the Plan to waive the copayments for the application of a multi-layer compression system. You say 
that the services should have been covered. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 surgery, including services provided at hospital outpatient facilities.  
 
You received the application of a multi-layer compression system from February 24, 2020 to March 23, 2020 
for a total of 5 visits. The application of a multi-layer compression system is considered an outpatient surgical 
procedure. Therefore, you are responsible to pay the total amount of $1,065, which is less than the total 
copayment amount.  
 
You have been asked to pay the total copayment amount of $1,065 for the application of a multi-layer 
compression system. The application of a multi-layer compression system falls within the outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments for the application of a multi-layer compression system 
provided from February 24, 2020 to March 23, 2020.
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 you need IRF care. The Plan denied your request. 
The Plan says the criteria for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 that, based on review of the available records, the patient does not meet criteria 
for IRF admission. The patient was medically stable with no evidence of need for supervision by a physical 
medicine and rehabilitation physician or needs acute rehab nursing care. Functionally, given her current level, 
though needing therapies she does not require IRF level of therapies. She is not expected to make a significant 
progress in a predictable period of time with IRF. The patient may benefit from further therapies but does not 
require an intensive therapy program. IRF admission is not medically necessary based on the patient?s current 
functional status and lack of medical complexity. 
 
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 pay for 10 units of iodinated contrast material (Q9967) provided 
November 25, 2019. 
 
You asked the Plan to pay for the contrast material. You say that the materials were medically necessary. The 
Plan denied your request. The Plan says the record does not support the 10 units 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 find that CPT code Q9967 is not supported in the medical record. Specifically, the record shows that only 
2mg of contrast was administered. The remainder must be billed as waste on a separate claim with the correct 
modifier. Based on this information, we decided that Medicare rules for coverage of the contrast material have 
not been met. Therefore, we decided that the Plan does not have to pay for 10 units of iodinated contrast 
material (Q9967) provided November 25, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 19, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. The records provided do not contain 
documentation of the ordering physician's intent that the tests be performed. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable oxygen equipment provided on December 29, 2019 
by an out of network (OON) provider. 
 
You asked the Plan to pay for portable oxygen equipment. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 has network providers 
available who can provide 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 portable oxygen equipment provided on December 
29, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 4, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. The records provided do not contain 
documentation of the ordering physician's intent that the tests be performed. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on February 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical MRI (CPT Code 72156), thoracic MRI (CPT 
Code 72157) and lumbar MRI (CPT Code 72158) provided to the enrollee on December 8, 2019. 
 
You asked the Plan to pay for the radiology services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the radiology services have not been 
met. Current Procedural Terminology (CPT) code 72157 26 remains not supported. The documentation 
submitted did not include documentation of Magnetic resonance (eg, proton) imaging, spinal canal and 
contents, without contrast material, followed by contrast material(s) and further sequences; thoracic; therefore, 
the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for 
additional information. We have insufficient documentation to corroborate the services so we can confirm 
Medicare coverage has been met. 
 
Current Procedural Terminology (CPT) code 72158 26 remains not supported. The documentation submitted 
did not include documentation of Magnetic resonance (eg, proton) imaging, spinal canal and contents, without 
contrast material, followed by contrast material(s) and further sequences; lumbar; therefore, the billed service 
cannot be verified. It is noted that multiple attempts were made to contact the provider for additional 
information. We have insufficient documentation to corroborate the services so we can confirm Medicare 
coverage has been met.  
 
Current Procedural Terminology (CPT) code 72156 26 52 remains not supported. The documentation 
submitted did not include documentation of Magnetic resonance (eg, proton) imaging, spinal canal and 
contents, without contrast material, followed by contrast material(s) and further sequences; cervical; therefore, 
the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for 
additional information. We have insufficient documentation to corroborate the services so we can confirm 
Medicare coverage has been met. Therefore, we decided that the Plan does not have to pay for the cervical MRI 
(CPT Code 72156), thoracic MRI (CPT Code 72157) and lumbar MRI (CPT Code 72158) provided to the 
enrollee on December 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have waive the copayment for an ambulance transport (A0427, A0425) 
provided April 18, 2020. 
 
You asked the Plan waive the copayment for the ambulance transport. You say that you didn't want an 
ambulance so the copayment should be waived. The Plan denied your request. The Plan says the correct 
copayment was applied as the services were rendered. 
 
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 Ambulance Services.  
 
You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport 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 waive the copayment for an 
ambulance transport (A0427, A0425) provided April 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for three additional intraoral x-rays provided on February 6, 
2019. 
 
You asked the Plan to pay for three additional intraoral x-rays. You say that the claim was submitted timely 
and should have been paid upon receipt. The Plan denied your request. The Plan says only one set of 
intraoral/periapical x-rays are covered per calendar year.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan also has a maximum benefit 
of one intraoral x-ray per calendar year. The Plan paid for one intraoral x-ray provided to the enrollee on 
February 6, 2019, which exhausted the benefit. Therefore, we decided that the Plan does not have to pay for 
three additional intraoral x-rays provided on February 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office services provided on 
January 31, 2020. 
 
You asked the Plan to waive the copayment for the specialist office services. You say that this provider is your 
primary care physician and they are also a specialist in cardiology. The Plan denied your request. The Plan says 
the claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received the specialist office services provided on January 31, 2020. The 
records show that you received cardiology services from this provider and it was billed as a specialty office 
visit. You are asked to pay a $20 copayment for the specialist office services. Your EOC states that enrollees 
must pay a $20 copayment for each Medicare-covered specialist visit. 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 specialist office services provided on January 31, 2020.