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 provided from 
February 9, 2020 to February 19, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that due to the quality of 
care you feel that the enrollee should not be responsible for the charges. The Plan denied your request. The 
Plan says the claims were processed correctly and the enrollee is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $390 copayment for days 1-5 for inpatient hospital care.  
 
The enrollee had an inpatient hospital stay from February 9, 2020 to February 19, 2020. Therefore, the enrollee 
is responsible to pay a $390 copayment for days 1-5 (February 9, 2020 to February 13, 2020). $390 
(copayment) x 5 (inpatient days) = $1,950.  
 
The enrollee has been asked to pay the total copayment amount of $1,950 for an inpatient hospital stay. An 
inpatient hospital stay falls within the inpatient hospital care benefit category. 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 copayment for an inpatient hospital stay provided from February 9, 2020 to February 19, 
2020.  
 
Your quality of care concerns will be forwarded to the appropriate Quality Improvement Organization for 
review.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EGD procedure (43235) performed on 
May 19, 2020. 
 
You asked the Plan to waive the copayment for an EGD procedure. You say that you have never before had a 
copayment for surgical services. The Plan denied your request. The Plan says the correct copayment was 
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 enrollees contract with the Plan clearly says that enrollees 
must pay a $150 copayment for each visit to an outpatient hospital facility.  
 
The enrollee has been asked to pay a $150 copayment for an EGD procedure. An EGD procedure falls within 
the "Outpatient hospital services" benefit category. 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 
copayment for an EGD procedure (43235) performed on May 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on January 13, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for radiology services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for radiology services provided on January 13, 2020 
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a hospital visit on June 17, 2019. 
 
You asked the Plan to waive the coinsurance for a hospital visit. You say that a representative of the Plan 
informed you that you should not pay for the first 20 days of a hospital stay. The Plan denied your request. The 
Plan says the correct copayment was 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 20% 
coinsurance for each Medicare-covered outpatient hospital visit.  
 
You have been asked to pay $2,473.83, or 20% of the Plan-allowed amount of $12,369.17, for a hospital visit. 
A hospital visit falls within the "Outpatient hospital services" benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for a hospital visit on June 17, 2019.  
 
Your complaint about receiving erroneous or misleading information from a representative of the Plan is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve echocardiography. 
 
You asked the Plan to pre-approve echocardiography. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 echocardiography. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has multiple risk factors for coronary artery disease. Although the enrollee is 
asymptomatic, the enrollee remains very active and the enrollee's EKG now shows evidence of a possible 
intercurrent anteroseptal myocardial infarction since the enrollee's prior EKG done one year before which was 
normal. Given the possibility of a new intercurrent but silent MI, stress echocardiography to both assess his 
regional wall motion and the possibility of ongoing exercise induced cardiac ischemia is both medically 
necessary and reasonable to fully assess the enrollee's clinical condition. Therefore, the enrollee meets criteria 
for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of echocardiography have been met. Therefore, we decided that the Plan has to 
pre-approve echocardiography.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on 
February 5, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. 
The Plan denied your request. The Plan says they were unable to discover any evidence of an established 
relationship between the member and the ordering physician. The Plan states there were no claims submitted 
for an evaluation and management service. The Plan states the review of claims history for this member, and a 
review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service 
with the ordering physician as required per CMS guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis 
(L0650) provided to the enrollee on February 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biopsy external ear (CPT Code 69100) provided on June 13, 
2019. 
 
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 the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Current Procedural Terminology (CPT) code 69100-59 (1 Unit) remains not supported. The submitted medical 
records do not contain sufficient detail to support that biopsy external ear was performed. Of note, the 
submitted medical records indicate that the service was planned, however do not indicate that it was performed; 
therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the 
provider for additional information. We have insufficient documentation to corroborate the services so we can 
confirm Medicare coverage has been met. 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 biopsy 
external ear (CPT Code 69100) provided on June 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on March 18, 
2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges 
because you were admitted to the hospital and the copayment should be waived. 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 $100 
copayment for emergency care.  
 
The medical records show that you were admitted under observation after you received emergency care on 
March 18, 2020. Observation is not considered a hospital admission. Therefore, you are responsible to pay the 
$100 copayment.  
 
You have been asked to pay a $100 copayment for emergency care. Emergency care 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 emergency care provided on 
March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves, and the lumbar-
sacral orthosis provided on February 3, 2020. 
 
You asked the Plan to pay for the knee orthoses (L1851) and suspension sleeves (L2397), or the lumbar-sacral 
orthosis (L0650). You say that the orthoses were medically necessary. The Plan denied your request. The Plan 
says criteria for telehealth services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthoses and 
suspension sleeves, and the lumbar-sacral orthosis provided on February 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
February 21, 2020 to March 6, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you had COVID-19 and 
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 $200 
copayment for days 1-18 for inpatient hospital care.  
 
You had an inpatient hospital stay from February 21, 2020 to March 6, 2020. Therefore, you are responsible to 
pay a $200 copayment for days 1-14 (February 21, 2020 to March 5, 2020). $200 (copayment) x 14 (inpatient 
days) = $2,800.  
 
You have been asked to pay the total copayment amount of $2,800 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 provided from February 21, 2020 to March 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a face-down positioning table. 
 
You asked the Plan to pre-approve face-down positioning table. You say that you are requesting payment 
reimbursement. The Plan denied your request. The Plan says the denial of payment for this item is correct, 
because this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a face-down positioning table.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on May 14, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physical therapy provided on May 14, 2020 by an 
out of network (OON) provider.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for coverage of IRF care. 
 
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 you are medically stable with no evidence of need for IRF care. The documentation 
does not support that there is a need for an intensive therapy program with 3 hours a day and an 
interdisciplinary approach to rehab care. Your needs can be met at a lower level of 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: 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 are in need of rehab services to strengthen your 
ankle. The Plan denied your request. The Plan says IRF care 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 you are medically stable after an ankle fracture with no evidence of need for IRF 
care three times a week or needing acute rehab nursing care. The documentation does not support that there is a 
need for an intensive therapy program with 3 hours a day and an interdisciplinary approach to rehab care. Your 
rehab needs can be met at a lower level of 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 4Kscore testing rendered on January 24, 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 the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that 4Kscore testing is covered when specific criteria 
are met. 
 
We looked at the file and Medicare rules. The file shows that the enrollee has a PSA of 2.42. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the 4Kscore testing rendered on January 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for the evaluation and management of an 
established patient provided on October 28, 2019. 
 
You asked the Plan to pay for the home visit (99350). You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says a home visit cannot be billed by a physician unless the physician or 
advanced practitioner was actually present in the enrollee's home. 
 
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  is not supported in the medical record. Specifically, there is no documentation that a 
physician was present during the home visit. Based on this information, we decided that Medicare rules for 
coverage of the home visit (99350) have not been met. Therefore, we decided that the Plan does not have to 
pay for the home visit for the evaluation and management of an established patient provided on October 28, 
2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic services provided on January 14, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for diagnostic services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the referring provider is also out-of-network. 
 
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 diagnostic services provided on January 14, 2020 
by an out of network (OON) provider.