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

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on August 4, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you have never been charged for 
your cancer tests. You say that you should have been notified of the cost up front. The Plan denied your 
request. The Plan says the copayment applied 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 $225 
copayment for each advanced imaging service. 
 
You have been asked to pay a $225 copayment for the CT scan. The CT scan 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 CT scan provided on August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed bridge for teeth # 18, 19, 20, 21 and 22. 
 
You asked the Plan to pre-approve a fixed bridge. You say that you cannot eat. You say that you do not have 
any teeth on your left side. You also say that your previously made denture does not work for you and you do 
not use it. The Plan denied your request. The Plan says prostheses are covered once every 5 plan years. The 
Plan says that the frequency limit has been reached. The Plan also says that you received a partial denture for 
the same teeth on June 11, 2018. 
 
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 frequency limit has been reached. 
Therefore, we decided that the Plan does not have to pre-approve a fixed bridge for teeth # 18, 19, 20, 21 and 
22.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telephonic consultation provided on April 17, 2020. 
 
You asked the Plan to pay for the telephonic consultation. The Plan denied your request. The Plan says the 
enrollee must use in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
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 a telephonic consultation provided on April 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 12, 2020 to August 
26, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 the medical services provided on August 12, 2020 
to August 26, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided June 24, 2020, to 
June 28, 2020. 
 
You asked the Plan to pay for the acute inpatient level of care. You say that review of the medical record 
supports that the inpatient level of care was medically necessary, reasonable and appropriate for all dates of 
service. The Plan denied your request. The Plan says the enrollee did not meet the criteria for continued 
inpatient stay. Care could be provided at a lower level of care.  
 
 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollee's 
condition can be managed safely only in the inpatient hospital setting.   
 
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 acute inpatient level of care. Our 
reviewer says that the enrollee does not meet the Medicare criteria for the inpatient hospital services. Our 
physician reviewer found the review has determined that on the hospital days under review (June 24, 2020, to 
June 28, 2020), the enrollee had stable vital signs and labs, was afebrile with good oxygenation, he was eating 
and taking medications (including pain medications) by mouth. The enrollee did not require any inpatient 
diagnostic studies or therapeutic interventions. The review has determined that the inpatient admission was not 
appropriate. The enrollee could have been admitted to observation. The enrollee could not have been 
discharged from the emergency department and followed up as an outpatient. 
 
The provider was in agreement with the denial for days June 29, 2020, to June 30, 2020 as the enrollee had 
agreed to inpatient hospice on June 29, 2020.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 acute inpatient level of care have 
not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care 
provided June 24, 2020, to June 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 14, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because the 
services rendered were medically necessary. The Plan denied your request. The Plan says the records do not 
support the necessity of the testing for the member's unique clinical scenario. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Additionally, the records do not include clear information 
regarding why this testing was ordered.  
 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 14, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant at surgical services provided on January 8, 
2020, billed with codes 47562-80 and 47379-80 provided by a licensed surgical assistant (LSA). 
 
You asked the Plan to pay for the surgical assistant services. You say that this procedure was complex which is 
why a surgical assistant was necessary. This should be paid. The Plan denied your request. The Plan says 
Medicare does not pay for these services when provided by an LSA. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant at surgical services 
provided on January 8, 2020, billed with codes 47562-80 and 47379-80 provided by a licensed surgical 
assistant (LSA).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on July 7, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that disagree with the charges because you 
were told that you would only owe a $90 copayment. 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 an MRI provided at an outpatient hospital facility.  
 
The record shows that you received an MRI at an outpatient hospital facility on July 7, 2020. Therefore, you 
are responsible to pay the $200 copayment.  
 
You have been asked to pay a $200 copayment for an MRI. An MRI falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an MRI provided on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 14, 2020, by an 
OON provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit and a nail debridement. You say that it was 
medically necessary for the enrollee to receive treatment. The Plan denied your request. The Plan says rules for 
payment have not been met. 
 
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 the medical services provided on January 14, 
2020, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 29, 2020. 

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because 
these services were requested by the referring physician. The Plan denied your request. The Plan says 
molecular genetic screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are 
done for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on July 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is ventilator-dependent. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee has a 
tracheostomy and is ventilator-dependent. She does not require services at the LTACH that are not available at 
the acute care hospital where she is currently receiving care. There are no services available at the LTACH that 
the enrollee requires that are not available at the health care setting being offered by the health plan. The 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 14, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on May 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the catheter placement provided on July 
13, 2020. 
 
You asked the Plan to waive the coinsurance for the catheter placement. You say that you received a letter that 
copayments would be waived. You say that you do not have the income to pay. The Plan denied your request. 
The Plan says the coinsurance applied 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 Medicare-covered surgery or other services at an in-network outpatient hospital or ambulatory 
surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. 
 
You have been asked to pay $1,028.34, which is 20% of the allowed amount for the catheter placement. The 
allowed amount is $5,141.70 (20% x $5,141.70 = $1,028.34). The catheter placement falls within the 
"Outpatient Surgery and Other Medical 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 coinsurance for the catheter placement provided on July 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (80307, G0481, 82542) provided on 
September 12, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON drug testing. You say that this was medically necessary. The Plan denied 
your request. The Plan says this 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 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 the drug testing (80307, G0481, 82542) provided 
on September 12, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic 
procedure coded 95999 provided on August 20, 2019. 
 
You asked the Plan to pay for the unlisted neurological or neuromuscular diagnostic 
procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the services billed are not payable. 
 
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 95999 is unlisted neurological or neuromuscular 
diagnostic procedure. 
 
We find that CPT code 95999 is not supported in the medical record. Specifically, the documentation shows 
that train of four testing was provided during surgery. This service is considered bundled with the surgery 
services and not separately payable. Based on this information, we decided that Medicare rules for coverage of 
the unlisted neurological or neuromuscular diagnostic 
procedure have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted 
neurological or neuromuscular diagnostic 
procedure coded 95999 provided on August 20, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost-sharing charges for wound debridement. We decided that the 
Plan does not have to reduce the cost-sharing charges for wound debridement to the amount you requested.  
 
You asked the Plan to reduce the cost-sharing charges for wound debridement. You say that you disagree with 
how the claims were coded. The Plan says that the claims were processed correctly and you are being charged 
the correct amount. 
 
We decided that the Plan has to reduce the cost-sharing charges for wound debridement from $1,543.46 
to $1,375. 
 
The Plan contract says that you must pay a $250 copayment for outpatient surgery services. The Plan is 
applying additional charges for wound debridement on March 2, 2020, and May 5, 2020. However, the Plan 
cannot charge more than a $250 copayment for outpatient surgery services. Therefore, we decided that the Plan 
has to reduce the cost-sharing charges for wound debridement from the total amount of $1,543.46 to $1,375.  
 
 
 
We also decided that the Plan does not have to reduce the cost-sharing charges for wound debridement 
to the amount you requested. 
 
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 surgery services. 
 
You received wound debridement from March 2, 2020, to May 26, 2020 for a total of 6 services. Wound 
debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $250 
copayment for each date of service. Please note, the plan is only charging you a $125 copayment for March 10, 
2020. The total amount you owe is: $1,375.  Therefore, we decided that the Plan does not have to reduce the 
cost-sharing charges for wound debridement to the amount you requested.  
 
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on March 4, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. The Plan denied your request. The Plan says the 
copayment applied 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 $120 
copayment for emergency services in an emergency room. 
 
You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the "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 the ER visit provided on March 
4, 2020.