Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 7 - January 
10, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the treating physician spent 
considerable time within the record outlining his/her opinion on providing post-stabilization care. The appellant 
says that the facts support this independent physician determination, given the grave condition of the patient, 
which mandated admission. The Plan denied your request. The Plan says the medical record supports that the 
enrollee was stable for transfer at 1:38pm on January 7, 2020. The Plan says that no material deterioration of 
her condition was likely, within the reasonable medical probability, to result from or occur during transfer. The 
Plan says that inpatient care at the out of network facility was not medically necessary to stabilize the enrollee. 
 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient hospital services. Our reviewer 
says that the criteria for out of network inpatient care have not been met. Our physician reviewer found the 
provided documentation did not show that the treating physician thought that the enrollee was not stable for 
transfer, and the evidence suggests he was stable for transfer around the time of admission. His vitals, including 
oxygenation were stable and treatments for bacteremia were initiated. 
 
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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided on January 7 - January 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Part B drugs provided on September 
12, 2019. 
 
You asked the Plan to waive the coinsurance for the Part B drugs. You sent your bill in for review. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing 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 20% of 
the cost for Part-B covered chemotherapy drugs and other Part-B covered drugs.  
 
You have been asked to pay $1,369.96 for the Part B drugs. The Part B drugs fall within the Medicare Part B 
prescription drugs" benefit category. See chart below. 
 
Date of Service Service Allowed Amount Coinsurance Member Liability 
September 12, 2019 Daratumumab 
injection 
$6,849.70 20% $1.369.95 
September 12, 2019 Zoledronic acid 
injection 
$0.04 20% $0.01 
Total    $1,369.96 
 
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 the Part B drugs provided on September 12, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) 
provided to the enrollee on September 30, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the record in the initial correspondence does not match the patient information. 
 
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 the denied codes is: 
 
CPT 80307: 
 
Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by 
instrument chemistry and analyzers (e.g.,  utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, 
RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, 
(DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation 
when performed, per date of service 
 
HCPCS G0483: 
 
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; 22 or more drug class(es), including metabolite(s) if performed 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found there 
was no physician notes or order to confirm the exact tests performed on 9/30/2019. The provided records do 
not support the codes, CPT 80307 and HCPCS G0483. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on September 
30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
August 15, 2018. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this is the second time 
this bill has been sent to you. You say this should be paid by your insurance. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing 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 $30 
copayment for each Medicare-covered specialist visit.  
 
You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls 
within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the specialist office visit provided on August 15, 2018.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on March 19, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says that the
Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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 did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for psychotherapy services provided on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection and copayment for outpatient 
hospital services provided by a participating provider on March 30, 2020. 
 
You asked the Plan to waive the coinsurance for an injection and copayment for outpatient hospital services. 
You say that you are on a fixed income and you cannot afford to pay. The Plan denied your request. The Plan 
says the correct coinsurance and copayment have 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 20% 
coinsurance and a $75 copayment for Medicare Part B prescription drugs and outpatient surgery/other services 
provided by an outpatient hospital.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $154.48. The total amount you are being asked to pay for an injection is $30.90 ($154.48 x 20% = 
$30.90). An injection falls within the Medicare Part B prescription drugs benefit category. You have also been 
asked to pay $58.56 which is less than your copayment amount of $75 for outpatient hospital services. The 
total amount you are being asked to pay is $89.46 ($30.90 + $58.56 = $89.46). Outpatient hospital services 
falls within the outpatient surgery/other services provided by 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.  
 
Therefore, we decided that the Plan does not have to waive the coinsurance for an injection and copayment for 
outpatient hospital services provided by a participating provider on March 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a finger orthosis provided on April 11, 
2019. 
 
You asked the Plan to waive the coinsurance for a finger orthosis. You say that you were told that you would 
not owe anything. 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 20% 
coinsurance for prosthetic devices and related supplies.  
 
You received a finger orthosis on April 11, 2019. The allowed amount is $79.02 and 20% of that is $15.80.  
 
You have been asked to pay the total coinsurance amount of $15.80 for a finger orthosis. A finger orthosis falls 
within the prosthetic devices and related 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 
coinsurance for a finger orthosis provided on April 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent 
deep vein thrombosis. The Plan denied your request. The Plan says PCDs billed by E0675 are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0675, E0673).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 9, 
2017. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because 
you were not informed that this provider is out-of-network. The Plan denied your request. The Plan says your 
request for payment as your provider has coded it is not a covered benefit under Medicare or the Plan. 
 
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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) 
provided on November 9, 2017.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (EM) services provided prior 
to anesthesia care on February 19, 2020. 
 
You asked the Plan to pay for the EM services. You say that this code should be paid due to the extensive 
workup required of the anesthesiologist prior to the surgery. The Plan denied your request. The Plan says 
evaluation of the patient prior to anesthesia is included in the payment for the anesthesia code. 
 
The Plan must follow Medicare rules. Medicare rules say that evaluation and management of the patient prior 
to anesthesia is included in the base units for the anesthesia code.  
 
In this case, the EM services cannot be separately paid as the cost is included in payment for code 01480. 
Therefore, we decided that the Plan does not have to pay for the evaluation and management (EM) services 
provided prior to anesthesia care on February 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (CPT Code 99233) provided to the 
enrollee on March 19, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says this service was reported with another evaluation, billed on the same day. The Plan 
states both providers are within the same group and have the same specialty; therefore, the Medicare rules have 
not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. This service is denied because it 
was reported with another evaluation with a provider that is within the same group and have the same specialty. 
Per review of our system and the specialties listed for the NPI's on the claims, both physicians are listed as 
Internal Medicine and CPT code 99233 is not supported as being performed for unrelated diagnosis per review 
of the medical records submitted. Therefore, we decided that the Plan does not have to pay for subsequent 
hospital care (CPT Code 99233) provided to the enrollee on March 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BLS non-emergency ambulance service (A0428) and ground 
mileage (A0425) provided on October 12, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that the decision to transport back was made by 
the hospital staff and the chance of it being a financial responsibility for you was not explained or addressed. 
The Plan denied your request. The Plan says the services did not meet the criteria for medical necessity. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation stated that the enrollee at the time was not bed-confined and could 
have been transported via seated transport without medical attendant. The documentation does not support that 
the enrollee required medical staff and specialized equipment only found in an ambulance. The provided 
documentation does not support that the ambulance transport was medically necessary for this enrollee. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for BLS non-emergency ambulance service (A0428) and ground mileage (A0425) 
provided on October 12, 2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a specialist office visit provided by a participating 
provider on January 21, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were told there was 
no copayment. The Plan denied your request. The Plan says that the correct copayment has been applied. 
 
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 failed to forward the correct Evidence of Coverage. Therefore, we 
decided that the Plan has to waive the copayment for a specialist office visit provided by a participating 
provider on January 21, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90791) provided July 31, 
2019. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were not pre-approved. There were 
network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for outpatient mental health services (90791) provided July 31, 2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for critical care services (99292) provided on March 8, 2020. 
 
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that CPT code 99292 is an add-on code and 
has not been billed with an appropriate primary code. 
 
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 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each 
additional 30 minutes (List separately in addition to code for primary service). 
 
We find that CPT code 99292 is supported in the record. Specifically, the record indicates that primary 
procedure code 99291 was billed by another physician of the same specialty on the same date of service. This 
means that billing 99292 is this case is appropriate. Based on this information, we decided that Medicare rules 
for coverage of the critical care services have been met. Therefore, we decided that the Plan has to pay for 
critical care services (99292) provided on March 8, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
February 6, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not have to 
pay the copayment because you were admitted to a hospital within three days of the emergency room visit. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $90 
copayment per visit for emergency care.  
 
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 
within the ?Emergency care? benefit category. The record shows the emergency room visit at one hospital and 
the inpatient stay at a separate hospital.  
 
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 emergency room visit provided on February 6, 2020.