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

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
August 14, 2021, to September 17, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you already paid this so 
this should be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $390 
copayment per day for days 1 through 5 of your stay.  
 
 
 
 
 You have been asked to pay $1,560 which is less than the standard $390 copayment per day 1 through 5 for 
inpatient hospital stay. 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 inpatient hospital stay provided from August 14, 2021, to 
September 17, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99232) provided February 19, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Original Medicare is liable for these services. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 5, 2022. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician services 
(99232) provided February 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80050, 80061, 82306, 82728, 82746, 82784, 
82785, 83001, 83002, 83036, 83970, 84165, 84439, 84480, 84481, 85610, 85730, 86141, 86317, 86803) 
provided on March 29, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the out-of-network services were not emergent or pre-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 had network providers 
available who could have provided 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 lab services (80050, 80061, 82306, 
82728, 82746, 82784, 82785, 83001, 83002, 83036, 83970, 84165, 84439, 84480, 84481, 85610, 85730, 86141, 
86317, 86803) provided on March 29, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on February 15, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you feel 
you should not be held accountable for this bill. The Plan denied your request. The Plan says your plan covers 
ambulance transportation only when you are actually transported by ambulance. The Plan also says since you 
were not transported by this ambulance, the service is not covered by your plan. 
 
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 February 15, 2022. 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 response and treatment with no 
transport (A0998) provided on February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro upper extremity device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has chronic arm weakness 
due to a stroke. The Plan denied your request. The Plan says the device is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation.  
 
We looked at the file and Medicare rules. In this case, there are no medical records to show that the requested 
device is indicated or medically necessary for the enrollees condition. Therefore, we decided that the Plan 
does not have to pre-approve a MyoPro upper extremity device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve dialysis services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-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 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 
dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care at the Diagnosis Related Group 
(DRG) originally billed. 
 You asked the Plan to pay for inpatient care at the DRG originally billed. You say that this claim should be 
paid at the DRG billed. The Plan denied your request. The Plan says diagnosis code E43 (unspecified severe 
protein calorie malnutrition) is not supported by the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code E43 (unspecified severe protein 
calorie malnutrition). 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 care at the DRG 
originally billed. Our reviewer says that diagnosis code E43 (unspecified severe protein calorie malnutrition) is 
not supported by the medical record. Our physician reviewer found this patient presented to the facility with the 
chief complaint of mid upper abdominal pain. This patient had a past medical history of small bowel 
obstruction, diabetes mellitus, atrial fibrillation, hypertension, liver transplant, and epilepsy. The emergency 
room physical exam noted normal pulmonary effort, neuro status as alert and oriented x3, no distress, and 
abdominal tenderness. The emergency physician documented that the patient was admitted with intestinal 
obstruction. The patient's respiratory rate was 18, and saturation of 97%. The history and physical included a 
physical assessment noting reducible right upper quadrant soft hernia, alert and oriented to person, place, and 
time, and no respiratory distress. Nutrition noted patient met American Society for Parenteral and Enteral 
Nutrition (ASPEN) criteria of malnutrition based on estimated Intake: Less than or equal to 50% for 5 or more 
days, Weight Loss: greater than 2% in 1 week, Body Fat: Moderate Loss, and Muscle Mass: Moderate Loss. 
The patients body mass index was noted as 20.4-21. The medical documentation is incomplete and conflicting 
in support of the condition of severe malnutrition.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital care at the Diagnosis Related Group (DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 27, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment 
for code 70496.  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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 27, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on February 24, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that the refraction should be covered. The Plan 
denied your request. The Plan says the services received were not for a routine eye exam.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the refraction is performed during a routine eye exam. 
 
We looked at the file and the Plan's rules. The record shows that the services received were not provided during 
a routine eye exam, but rather an exam for bilateral dermatochalasis, pinguecula, posterior capsular opacity, 
pseudophakia and dry eye. Based on this information, we decided that the Plan's rules for coverage of the eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction 
(92015) provided on February 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for trimming of dystrophic nails and the paring of benign 
hyperkeratotic lesion provided on November 12, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the trimming of dystrophic nails and the paring of benign hyperkeratotic lesion. 
You say that you are requesting that the Plan use the facility authorization to process your claim. You say the 
physician has treated the enrollee with good will and based on medical necessity. The Plan denied your request. 
The Plan says no 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 
trimming of dystrophic nails and the paring of benign hyperkeratotic lesion. We found no exception that would 
require the Plan to pay for the trimming of dystrophic nails and the paring of benign hyperkeratotic lesion. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for trimming of dystrophic nails and the paring of benign 
hyperkeratotic lesion provided on November 12, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit provided on 
March 10, 2022. 
 
You asked the Plan to waive the copayment for the outpatient office visit. You say that you called for a routine 
eye exam and did not go there for a health issue. You also say that the claim states you are a diabetic, which 
you are not, and the doctor did not find any issues with your eyes. The Plan denied your request. The Plan says 
you were seen for a diabetic eye exam. The Plan also says that this claim processed correctly with a $35 
copayment. 
 
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 each Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye.  
 
 
  You have been asked to pay a $35 copayment for the outpatient office visit. The outpatient office, which was 
for a diabetic eye exam, visit falls within the Vision care benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the outpatient office visit provided on March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested services. You say that you were approved by your previous 
insurance. The Plan denied your request. The Plan says you do not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of the requested services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on January 22, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your blood 
sugar was low, and your wife called 911. You also say that the paramedics revived you, and you felt better after 
45 minutes. The Plan denied your request. The Plan says your plan covers ambulance transportation only when 
you are actually transported by ambulance. The Plan also says that since you were not transported by this 
ambulance, the service is not covered by your plan. 
 
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 January 22, 2021. 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 response and treatment with no 
transport (A0998) provided on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit provided on January 25, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy visit. You say that the claim denied because you are not an in-
network provider. You say you have been a provider since May 1, 2012. The Plan denied your request. The 
Plan says no 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 
psychotherapy visit. We found no exception that would require the Plan to pay for the psychotherapy visit. The 
record shows you are an out-of-network provider. Therefore, we decided that the Plan does not have to pay for 
the psychotherapy visit provided on January 25, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a sacroiliac joint injection performed on 
August 12, 2021. 
 
You asked the Plan to waive the copayment for the injection. You say that the provider is a contracted provider 
and the service should be covered. 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 $225 
copayment for services provided at an ambulatory surgical center.  
 
You have been asked to pay a $225 copayment for the injection. Please note that there is no difference in 
coverage for in-network or out-of-network services. The injection falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a sacroiliac joint injection 
performed on August 12, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary, and you need intense 
rehabilitation. The Plan denied your request. The Plan says that the documentation does not show that the 
enrollee completed their full acute hospital treatment and shows their condition requires further care in the 
hospital. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the clinical documentation shows that the enrollee has multiple active medical issues and would 
benefit from close medical supervision on an inpatient basis. Physical medicine and rehabilitation along with 
evaluating therapists all recommend intense therapy and the enrollee would significantly benefit. IRF criteria 
has been met. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
IRF admission and services.  
  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit and debridement 
provided on February 02, 2022, by an OON provider. 
 
You asked the Plan to pay for a subsequent nursing facility care visit and debridement. You say that the 
enrollee is a resident in the nursing home and has authorization on file for all care at the facility including 
consultations. The Plan denied your request. The Plan says the out-of-network 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 had network providers 
available who could have provided 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 a subsequent nursing facility care visit and 
debridement provided on February 02, 2022, by an OON provider.