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

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 28, 
2020, to January 30, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
charges. 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 $300 
copayment for days 1-5 for inpatient hospital care.  
 
You received an inpatient hospital stay from January 28, 2020, to January 30, 2020. Therefore, you are 
responsible to pay a $300 copayment for days 1-2 (January 28, 2020, to January 29, 2020). $300 (copayment) x 
2 (inpatient days) = $600.  
 
You have been asked to pay the total copayment amount of $600 for an inpatient hospital stay. An inpatient 
hospital stay 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 an inpatient hospital stay from January 28, 2020, to January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an urgent care visit (99213) and a chest X-
ray (71046) on February 8, 2020. 
 
You asked the Plan to waive the copayments for an urgent care visit and a chest X-ray. You say that the 
enrollee's diagnosis indicates these services are related to COVID-19. The Plan denied your request. The Plan 
says the correct copayments were 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $40 copayment for each urgently needed visit in a non-contracted Urgent Care Center or walk-in 
clinic in the United States. The enrollee's contract also says that enrollees must pay a $14 copayment for each 
Medicare-covered standard X-ray service. 
 
The enrollee has been asked to pay a $40 copayment for an urgent care visit and a $14 copayment for a chest 
X-ray. An urgent care visit falls within the "Urgently Needed Services" benefit category. A chest X-ray falls 
within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The medical 
records provided do not support that the enrollee was diagnosed with COVID-19. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayments for an urgent care visit (99213) and a chest X-ray (71046) on February 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion services (S9328) provided March 12, 2020 to June 
25, 2020. 
 
You asked the Plan to pay for the infusion services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the billed CPT code is 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. 
 
We find that CPT code S9328 is not supported in the medical record. Specifically, "S" codes are not used for 
Medicare purposes. This CPT code is listed with a status of "I" and is not valid for Medicare payment. Based 
on this information, we decided that Medicare rules for coverage of the infusion services have not been met.  
Therefore, we decided that the Plan does not have to pay for infusion services (S9328) provided March 12, 
2020 to June 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray provided on June 29, 2020. 
 
You asked the Plan to pay for the intraoral x-ray. You say that this was your first use of this dental benefit since 
signing up. You say that you couldn't have exhausted your benefit for a dental radiograph. The Plan denied 
your request. The Plan says payment cannot be issued for dental services above the maximum of $1,000. 
 
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, you also have an annual maximum of 
$1,000. The Plan paid $1,000 toward your dental services received on May 20, 2020, and June 11, 2020, which 
exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray 
provided on June 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for pathology services provided by a 
participating provider on June 20, 2020 to June 23, 2020. 
 
You asked the Plan to waive the copayment for pathology services. You say that you do not agree with this 
copayment. The Plan denied your request. The Plan says you have been asked to pay less than your copayment 
amount. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for outpatient diagnostic tests/lab/outpatient hospital.  
 
You have been asked to pay a total of $90 for pathology services. Pathology services fall within the outpatient 
diagnostic tests/lab/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 copayment for 
pathology services provided by a participating provider on June 20, 2020 to June 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Euflexxa is only covered for certain indications. 
 
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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the documentation supports imaging confirmation of advanced osteoarthritis. The 
records also document the use of analgesics. The period that analgesics have been utilized is not specified. The 
records contain an order for physical therapy. The LCA states that the documentation in the enrollee's medical 
record must support the enrollee failed to respond adequately over a three-month period to a past history of 
treatment with analgesics and conservative nonpharmacological therapy (exercise or physical therapy, weight 
loss if appropriate, use of assistive devices). Based upon the provided medical records the enrollee has not 
satisfied these requirements. Therefore, the enrollee does not meet criteria for Euflexxa. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eyelid repair (67900) provided December 21, 2018. 
 
You asked the Plan to pay for the eyelid repair (67900). You say that the service was medically necessary. The 
Plan denied your request. The Plan says insufficient records were provided for review. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
 
We looked at the file and Medicare rules. Insufficient records were provided to the plan for review. Per Local 
Coverage Determination (LCD): Blepharoplasty, Eyelid Surgery, and Brow Lift (L34411), color photographs 
must be provided with the records to support medical necessity of the eyebrow repair. The plan made multiple 
requests for the required documentation but did not receive it. Based on this information, we decided that 
Medicare rules for coverage of the eyelid repair (67900) have not been met. Therefore, we decided that the Plan 
does not have to pay for an eyelid repair (67900) provided December 21, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a lab test with an out-of-network provider 
at the in-network benefit level. 

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this out-of-network referral at the in-network benefit level. Therefore, we decided that 
the Plan does not have to pre-approve a referral for a lab test with an out-of-network provider at the in-network 
benefit level.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not have 
complex medical conditions that support the need for supervision by a rehab physician or intensive therapy. 
 
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 physician reviewer found 
that you are medically stable with no complexity of care. There is no evidence of medical issues that require 
monitoring by an inpatient rehab physician three times a week. The documentation does not support that there 
is a need for an intensive therapy program with 3 hours a day at the current level of function and an 
interdisciplinary approach to rehab 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 definitive drug test (G0480) provided on May 26, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for drug test. You say that you performed medically necessary services referred by 
another provider. The Plan denied your request. The Plan says prior authorization must be obtained for non-
emergent services rendered by an out-of-network provider. 
 
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 definitive drug test (G0480) provided on May 
26, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for 3 fillings provided on June 17, 2020. 
 
You asked the Plan to pay the full amount for the dental services. You say that the fillings are covered under 
your plan. The Plan denied your request. The Plan says 2 fillings per calendar year are covered. The Plan says 
the frequency limit has been exceeded. The Plan says 2 fillings were paid for this date of service. The Plan also 
says that the cost sharing amount still applies. 
 
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 and fillings are a covered service, the 
frequency limit of 2 per calendar year has been exceeded. The record shows that the Plan paid for 2 fillings that 
you received on this date of service. Additionally, the applied cost sharing amounts are a contractual obligation 
you agreed to when you enrolled in the Plan?s dental coverage. Therefore, we decided that the Plan does not 
have to pay the full amount for 3 fillings provided on June 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on August 10, 2020. 
 
You asked the Plan to waive the copayment for lab services. You say that you should only owe a $5 
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 $5 
copayment for lab services provided in a primary care providers office, specialists office or freestanding lab 
and a $50 copayment for lab services provided in an outpatient hospital facility.  
 
You received lab services at an outpatient hospital facility on August 10, 2020. Therefore, you are responsible 
to pay the $50 copayment.  
 
You have been asked to pay a $50 copayment for lab services. Lab services fall 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 lab services provided on August 10, 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 these services. The Plan denied your 
request. The Plan says you are at your baseline level of function. 
 
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 the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
atrial fibrillation and heart failure. Your medical problems are stable. There are no identified problems that 
need inpatient medical management. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. The medical record supports a need for physical and occupational therapy, but 
it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advanced life support (ALS) supplies for air ambulance 
transportation provided on April 18, 2020. 
 
You asked the Plan to pay for ambulance supplies. You say that you submitted this claim with correct and valid 
modifiers and are appealing with supporting documentation. The Plan denied your request. The Plan says the 
denial of payment for these supplies is correct, because ALS supplies are included in the fee schedule payment 
for ambulance transport and are not separately payable. The Plan also says that they have approved payment 
for the transportation itself, so this denial is only for the separately billed supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that supplies provided as part of ambulance transport 
are included in the fee schedule base payment rate and are not separately payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for advanced life support (ALS) supplies for air ambulance transportation provided on April 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis provided on March 25, 2020. 
 
You asked the Plan to pay for the ankle foot orthosis. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the documentation is missing required information. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the documentation did not include an itemized shipping/billing invoice to indicate the specific 
supplies, or proof of delivery for the billed date of service. The submitted invoice indicates the item was 
shipping on May 13, 2020 and delivered on May 16, 2020. The billed date of service is March 25, 2020. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis provided on March 25, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 68761) provided on March 19, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
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 68761 is "Closure of the lacrimal punctum; by plug, 
each". 
 
We asked our coding 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 use 
of CPT 68761 is not supported by the records provided. Our coding reviewer found that CPT 68761 is not 
documented in the procedure report submitted. 
 
We looked at this coder?s review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 68761) provided on March 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral x-ray (D0230) provided on June 10, 
2020. 
 
You asked the Plan to pay for the additional intraoral x-ray. You say that the service is covered. You say that 
you have never paid for x-rays before. You say that when you checked out, you were given a statement with a 
balance of $0. You also say that if these services are not paid that you will be changing insurance companies. 
The Plan denied your request. The Plan says 1 intraoral x-ray per calendar year is covered. The Plan also says 
that the frequency limit has been exceeded.  
 
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 and intraoral x-rays are a covered 
service, the frequency limit of 1 per calendar year has been exceeded. The record shows that the Plan paid for 1 
intraoral x-ray provided on the date of service. Therefore, we decided that the Plan does not have to pay for the 
additional intraoral x-ray (D0230) provided on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network neurosurgery provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says these services are available in-plan in an appropriate timeframe. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network neurosurgery provider.