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

 
We decided that the Plan does not have to pay for inpatient hospital care from July 4, 2019 through July 7, 
2019 provided by an out-of-country provider. 
 
You asked the Plan to pay for inpatient hospital care. You say that you are requesting reimbursement of 
services rendered. The Plan denied your request. The Plan says there is a lack of medical records. 
 
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 inpatient hospital care have not been met. Review of the file shows 
that there are is no medical records provided to support your request. Therefore, we decided that the Plan does 
not have to pay for inpatient hospital care from July 4, 2019 through July 7, 2019 provided by an out-of-
country provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on February 19, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and
approved for payment. You say that your physician was called in by the facility. The Plan denied your request.
The Plan says prior authorization was 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 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 podiatry services provided on February 19, 2020
by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on February 19, 
2020. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you were not informed you would 
have a copayment and you say you should not be responsible for the charges. 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 $110 
copayment for each Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or at a freestanding facility (such as a radiology center or medical clinic). For this date of 
service, you have been asked to pay the allowed amount of the claim because this amount is less than the $110 
copayment for the ultrasound. 
 
You have been asked to pay a $98.35 copayment for the ultrasound. The ultrasound 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 ultrasound provided on February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0482) 
provided to the enrollee on October 14, 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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of 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 G0482: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed.
 
We 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 the 
documentation submitted did not include a physician order/lab requisition or medical records stating exactly 
what tests are to be performed. The records do not support the above denied codes. 
 
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 G0482) provided to the enrollee on October 14, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye refraction services received on March 5, 2020. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says refraction services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover eye refraction.  
 
The services you asked the Plan to pay for are considered refraction. Therefore, we decided that the Plan does 
not have to pay for eye refraction services received on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on February 27, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that if you knew it would be this 
much you would have never had these services performed. 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 $250 
copayment for outpatient surgery.  
 
You have been asked to pay a $250 copayment for an outpatient surgery. The injection you received is 
considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls 
within the outpatient surgery 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 
outpatient surgery provided by a participating provider on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
February 26, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you disagree with the 
charges because you have had the procedure done many times and never had a 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 $250 
copayment for outpatient surgery, including services provided at hospital facilities and ambulatory surgical 
centers.  
 
You have been asked to pay a $250 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls 
within the outpatient surgery, including services provided at hospital 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 copayment for a diagnostic colonoscopy 
provided on February 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on October 28, 2019 by a non-
participating provider. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says you do not have out-of-network benefits. 
 
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. 
 
Review of the file show that you received the dental services on October 28, 2019 by a non-participating 
provider. Your EOC states, "the supplemental dental provider will manage your dental benefits. To locate a 
network provider, you may contact Customer Service or search the online provider directory." 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 dental services provided on October 28, 2019 by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and bone replacement graft 
provided on March 11, 2020. 
 
You asked the Plan to pay for the cone beam CT capture and bone replacement graft. You say that you were 
informed you would be responsible for half the amount. You say that you can't pay it off. The Plan denied your 
request. The Plan says the services are not covered benefits. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam CT capture and bone replacement graft provided on March 11, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from June 7, 2019 to 
June 26, 2019. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
100 day SNF benefit had been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from April 8, 2019 to 
October 23, 2019. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing services provided from June 7, 2019 to June 26, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on November 23, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on November 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you would like reconsideration 
because the member's clinical data supports this therapy as an effective long term therapy for chronic back and 
leg pain. The Plan denied your request. The Plan says there is no network deficiency and this is not an 
emergent procedure. 
 
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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PET scan with concurrently acquired computed tomography 
(CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815) provided 
to the enrollee on December 13, 2019. 
 
You asked the Plan to pay for the PET scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says it was not reported with an appropriate diagnosis. 
 
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 PET scan have not been met. Review of the file shows that for 
PET Scans there are certain diagnosis codes that should be billed for these services. C56.9 (Malignant 
neoplasm of unspecified ovary) is not listed as an acceptable diagnosis code. Therefore, we decided that the 
Plan does not have to pay for PET scan with concurrently acquired computed tomography (CT) for attenuation 
correction and anatomical localization imaging; skull base to mid-thigh (78815) provided to the enrollee on 
December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92014) provided on  
January 21, 2020. 
 
You asked the Plan to waive the copayment for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied 
correctly to the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for exams to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay a $40 copayment for the diagnostic vision exam provided. 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 eye exam (92014) provided on January 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that on the date of service you had an accident 
where you had wandered off and fell. An ambulance was called for you and the responders provided you with 
treatment at the scene. You say that if the emergency responders had not come and provided treatment when 
they did, the situation could have taken a turn for the worse. You asked the Plan to review their denial and 
approve coverage for the services. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 24, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 80mg Oxycodone tablets. 
 
You asked the Plan to pre-approve the Oxycodone. You say that you would like reconsideration because this 
drug is medically necessary. The Plan denied your request. The Plan says this medication does not fall under 
the member's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 80mg Oxycodone tablets.  
 
Benefits for the Oxycodone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission for a colonoscopy. 
 
You asked the Plan to pre-approve the inpatient admission. You say that you would like reconsideration 
because the inpatient admission is medically necessary. The Plan denied your request. The Plan says the 
member does not meet criteria for inpatient admission for an outpatient procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 inpatient admission. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not suggest the member would be expected to have 
complications or post-procedure needs to warrant inpatient services approval prior to the procedure. There was 
no indication the member would need acute care services for more than two midnights. 
 
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 admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient admission for a colonoscopy.
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. The Plan denied your request. The Plan says IRF admission is not 
medically necessary. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires an 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.