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

 
We decided that the Plan does not have to pay for assembly and operation of a pump with oxygenator or heat 
exchanger provided on March 25, 2020. 
 
You asked the Plan to pay for pump assembly/operation. You say that this charge is for the perfusionist that set 
up and operated the heart-lung machine for surgery. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because this service must be furnished directly by the hospital or billed 
through the hospital under arrangements. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  
 
We looked at the file and Medicare rules. This service must be furnished directly by the hospital or billed 
through the hospital under arrangements, therefore this service is not separately payable by the Plan. Based on 
this information, we decided that Medicare rules for coverage of pump assembly/operation have not been met. 
Therefore, we decided that the Plan does not have to pay for assembly and operation of a pump with 
oxygenator or heat exchanger provided on March 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a behavioral health inpatient admission provided from March 
23, 2020, through March 26, 2020. 
 
You asked the Plan to pay for the behavioral health inpatient admission. 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 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 behavioral health inpatient admission provided from March 23, 
2020, through March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 13, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. 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 physician's services provided on June 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. You say that you would like reconsideration because the 
member would benefit from these injections for diagnostic and surgical assessment purposes. The Plan denied 
your request. The Plan says this service is not medically necessary. 
 
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 injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of conservative care or physical therapy. The requested procedure is 
supported for predominantly axial pain that is not associated with radiculopathy or neurogenic claudication.  
The office notes indicate the patient has chronic back pain with radiation into the right thigh and numbness 
with paresthesias. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on June 2, 2020, to June 3, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you cannot believe that 
during a pandemic you would get this high of a copayment for emergency surgery. 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 $325 
copayment for outpatient surgery/in-network/outpatient hospital facility.  
 
You have been asked to pay a $325 copayment for an outpatient surgery. The correct copayment has been 
applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/in-
network/outpatient hospital facility 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 June 2, 2020, to June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 28, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
physicians services. 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 physician's services provided on February 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hand finger orthosis (L3913) provided on March 17, 2020. 
 
You asked the Plan to pay for a hand finger orthosis. You say that this was urgently needed. The Plan denied 
your request. The Plan says this provider is not a certified DME supplier. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to be reimbursed for the DME supplies 
that they sell, providers must separately enroll in Medicare as a supplier of DME. 
 
We looked at the file and Medicare rules. The records do not show that the provider in this case is enrolled in 
Medicare as a DME supplier. Based on this information, we decided that Medicare rules for coverage of a hand 
finger orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a hand finger 
orthosis (L3913) provided on March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 24, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-
network with the Plan and the referring provider is also out-of-network with 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 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 April 24, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electronic analysis of programmable, implanted pump for 
intrathecal or epidural drug infusion (62370)  and Drugs unclassified injection (J3490) provided February 18, 
2020. 
 
You asked the Plan to pay for reservoir/pump implantation procedures and injection. You say that the medical 
records and invoice are attached. Please review and reprocess the claim for payment. The Plan denied your 
request. The Plan says payment is not allowed because this claim was submitted with incomplete invoice 
information. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, this claim was submitted with incomplete invoice information. A corrected claim must be 
submitted with complete invoice information. Based on this information, we decided that Medicare rules for 
coverage of reservoir/pump implantation procedures and injection have not been met. Therefore, we decided 
that the Plan does not have to pay for electronic analysis of programmable, implanted pump for intrathecal or 
epidural drug infusion (62370)  and Drugs unclassified injection (J3490) provided February 18, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for administration of the flu vaccine provided on October 7, 
2019. 
 
You asked the Plan to pay for the vaccination. You say that the Plan denied your request. The Plan says The 
Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of 
election to the date of discharge or revocation. The Plan also says that during the election, fee-for-service 
Medicare also covers attending physician services and all care unrelated to the terminal illness until the first 
day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for administration of the flu vaccine provided on October 7, 
2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient behavioral health services 
provided by a participating provider on January 9, 2020, through May 1, 2020. 
 
You asked the Plan to waive the copayment for outpatient behavioral health services. You say that you cannot 
afford all of these copayments. The Plan denied your request. The Plan says the correct copayments 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 $20 
copayment for outpatient mental health care.  
 
You have been asked to pay a $20 copayment for each outpatient behavioral health services. The total amount 
you are being asked to pay is $60 ($20 x 3 visits = $60). Outpatient behavioral health services fall within the 
outpatient mental health 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 outpatient 
behavioral health services provided by a participating provider on January 9, 2020, through May 1, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and urine analysis provided on October 7, 
2019. 
 
You asked the Plan to pay for the office visit and urine analysis. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the office visit and urine analysis provided on October 7, 
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0425) provided April 28, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the transportation was medically necessary. 
The Plan denied your request. The Plan says the transport was not provided to a Medicare covered destination. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for ambulance services (A0425) provided April 28, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral- periapical x-rays provided on December 23, 
2019. 
 
You asked the Plan to pay for the intraoral- periapical x-rays. You say that the only benefits offered by the plan 
are exams, x-rays and cleanings. You say that you made no other claims for x-rays in 2019 so you don't see 
why this claim was denied. 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 Plans 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 
intraoral- periapical x-rays provided on December 23, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient psychiatric hospital services provided June 11, 2020 to June 
23, 2020. 
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that the inpatient services were 
medically necessary. The Plan denied your request. The Plan says that the services were not pre-authorized and 
inpatient mental health coverage criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our 
reviewer says that the services at issue were medically necessary. Our physician reviewer found admission of 
this enrollee does meet criteria for acute inpatient mental health treatment as although the enrollee was not 
shown to be a danger to herself or others, she had bizarre behaviors and visual hallucinations. The services 
were urgent in nature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pay for inpatient psychiatric hospital services provided June 11, 2020 to June 23, 2020.  

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on July 5, 2019. 
 
You asked the Plan to pay for drug test. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for this service is correct, because the documentation submitted 
does not include a valid physician order, lab requisition, or medical records to support the test billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided 
that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing provided on July 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the case presentation- extensive treatment planning provided 
on July 1, 2020. 
 
You asked the Plan to pay for the case presentation- extensive treatment planning. You say that you were 
unaware the service was being received. You say that there was no extensive treatment plan mentioned. The 
Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 case 
presentation- extensive treatment planning provided on July 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assisted living facility care (99336, 96127) provided on 
November 22, 2019 to January 14, 2020. 
 
You asked the Plan to pay for the assisted living facility care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says these services were not emergent or pre-authorized. 
There were network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the assisted living facility care (99336, 96127) provided on November 22, 2019 
to January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 3, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
physicians services. 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 physician's services provided on January 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or 
heat exchanger (99190) provided on April 6, 2020. 
 
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. 
You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this 
service is included in the DRG. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the 
OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of 
"C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as 
"inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the 
Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger 
(99190) provided on April 6, 2020.