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

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided on 
January 2, 2022. 
 
You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 in-network inpatient hospital care.  
 
 
 
 
 
 Your contract with the Plan clearly says that you must pay 20% coinsurance for in-network inpatient hospital 
care. However, you have only been asked to pay $1,281.45, which is less than the 20% coinsurance amount. 
 
 
Date of Service Service Plan Allowance Cost Per Contract Your 
Responsibility 
January 2, 2022 Inpatient Hospital 
Care 
$15,179.64 
 
 
 
20% Coinsurance $1,281.45 
 
This item/service falls within the in-network 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 coinsurance for inpatient hospital care provided on January 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care provided on March 13, 2022, to March 14, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital care. You say that these services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained for these services. 
 
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 hospital care provided on March 13, 2022, to 
March 14, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total shoulder arthroplasty of the glenohumeral joint. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you are being treated for primary 
osteoarthritis of the right shoulder and underwent reverse total shoulder arthroplasty on April 12, 2022. There 
is no detailed documentation of a trial and failure of recent reasonable and comprehensive less-invasive 
conservative care measures prior to the considered total shoulder replacement surgery. There are limited large-
scale, long-term references showing the safety and effectiveness of the requested surgery in this clinical setting. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested total shoulder arthroplasty of the glenohumeral joint, in 
this case, is not medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a total shoulder arthroplasty of the glenohumeral joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99350 billed for date of service January 11, 
2022. 
 
You asked the Plan to pay for procedure code 99350. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 99350 is bundled into payment for code 97163.  
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 99350 
is a column II code to column I code 97163. 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 99350 billed for date of service January 11, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 
13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient care at the current hospital and can remain there until ready for discharge to a lower level of care such 
as an inpatient rehabilitation facility or even a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory testing services provided on March 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that the test identifies possible treatment options. The 
Plan denied your request. The Plan says that the services do not meet Medicare criteria.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. was provided to a patient with a solid tumor. The FDA approval notice 
indicates that this panel is approved for solid tumors. The Plan has not shown the testing does not meet one of 
the exceptions for the billed date of service. Therefore, we decided that the Plan has to pay for the laboratory 
testing services provided on March 16, 2022.  
 
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 telehealth services (99441) provided on April 4, 2022. 
 
You asked the Plan to pay for the telehealth services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 99441 is not supported in the medical record. Specifically, a previous evaluation and 
management service was provided in the 7 days before this service. Code 99212 was billed on March 31, 2022. 
Based on this information, we decided that Medicare rules for coverage of the telehealth services have not been 
met. Therefore, we decided that the Plan does not have to pay for telehealth services (99441) provided on April 
4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel provided on February 22, 2022. 
 
You asked the Plan to pay for the testing services. You say that the service was coded appropriately. The Plan 
denied your request. The Plan says the code is excluded and not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 80050 is general health panel. This panel must include 
the following: Comprehensive metabolic panel (80053) Blood count, complete (CBC), automated and 
automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated 
(85027) and appropriate manual differential WBC count (85007 or 85009) Thyroid stimulating hormone (TSH) 
(84443). 
 We find that CPT code 80050 is not supported. The code is not covered by Medicare. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the general health panel provided on February 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base 
to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET-CT scan. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this imaging is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 a PET-CT scan. Our reviewer says that 
the requested imaging service is not medically necessary and reasonable. Our physician reviewer found the 
enrollee has chronic obstructive pulmonary disease and previous COVID-19. A chest CT on February 24, 
2022, showed two pulmonary nodules. A follow-up chest CT on June 22, 2022, showed that one of the nodules 
had increased in size, and a PET-CT was recommended. A CT-guided needle biopsy of the lesion was planned 
for August 4, 2022, but the lesion had resolved at that point, so no biopsy was done. Since the lesion has 
resolved, the PET-CT is no longer necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET-CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine 
without contrast (72141). 
 
You asked the Plan to pre-approve an MRI of the cervical spine. You say that this imaging is medically 
necessary as you have had x-rays with abnormal findings and are unable to use or are unresponsive to certain 
medications. The Plan denied your request. The Plan says this service is not medically necessary as there is no 
indication that you have undergone six weeks of treatment within the last three months. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the cervical spine. Our 
reviewer says that the requested MRI is not medically necessary. Our physician reviewer found that you have 
had prior lumbar fusion. The notes state that physical therapy has been tried; however, it is unclear if this 
therapy was for the back or neck as no additional details were provided. The physical exam revealed no red 
flags such as documented upper extremity weakness or absent/diminished reflexes. Without a documented red 
flag, the medical necessity of the requested MRI is not demonstrated without a six-week trial of monitored 
physical therapy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the cervical spine have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine without contrast 
(72141).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on June 1, 
2022, June 8, 2022, and June 15, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you were not informed that you 
were going to have a coinsurance payment. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 Medicare-covered Part B Chemotherapy drugs and other Part B drugs. The allowed amounts of 
these part B drugs total $928.5, resulting in a total coinsurance amount $185.70. 
 
You have been asked to pay 20% coinsurance for Part B drugs. This item/service falls within the Medicare-
covered Part B Chemotherapy drugs and other Part B drugs 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 Medicare Part B drugs provided on June 1, 2022, June 8, 2022, and June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Navage nasal care. 
 
You asked the Plan to pre-approve Navage nasal care. You say that it is a medical necessity for you to have it. 
The Plan denied your request. The Plan says your records do not say why you cannot use the nasal rinse kit 
listed in your Plan's 2022 Member Handbook, or that you tried the nasal rinse kit from the Plan's 2022 Member 
Handbook. The Plan states the records also do not say that the Navage nasal care irrigation kit would work 
better for you than the nasal rinse kit available from the Plan's 2022 Member Handbook. 
 
The Plan must follow Medicare rules. There is an alternative nasal irrigation kit is available at no cost via your 
Plan's 2022 Over-The-Counter (OTC) Benefit handbook. You have a $70 allowance for over-the-counter items 
every three (3) months. The nasal rinse is listed on page 8 of the Plan's 2022 Over-The-Counter (OTC) Benefit 
handbook. The Plan states you are encouraged to utilize the no cost nasal rinse kit available in the handbook 
and discuss referral to an ear, nose, and throat (ENT) doctor for further treatment options. Therefore, we 
decided that the Plan does not have to pre-approve Navage nasal care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9338 billed for date of service May 2, 2022. 
 
You asked the Plan to pay for procedure code S9338. You say that this is the correct code to be billed. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9338 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code S9338 billed for date of service May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100). 
 
You asked the Plan to pre-approve additional non-emergency transportation (A0100). You say that you need to 
attend an appointment for your right knee since you have recently had surgery. You also say you do not have 
any type of transport anymore. The Plan denied your request. The Plan says additional trips in excess of 24 
one-way trips are non-covered by the Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 24 trips every year trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on January 7, 2022.  
You asked the Plan to pay for the lab services. You say that the denial of payment is incorrect. The Plan denied 
your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the lab services were not billed with a modifier suitable for payment.  Based on this information, 
we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab testing services provided on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telephone visit provided on April 13, 
2022. 
 
You asked the Plan to waive the copayment for a telephone visit. You say that you had a telephone evaluation. 
You also say that you told the provider of your medical history. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
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 specialist virtual telehalth services. 
 
You have been asked to pay a $35 copayment for a telephone visit. This item/service falls within the specialist 
virtual telehalth 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 copayment for a telephone 
visit provided on April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204, 99214) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you are entitled to seek a second opinion from a 
surgeon outside of the medical group. Your provider states there are no other options, but according to 
information available on the internet from refutable intuitions, there are other options available for a patient 
with spinal stenosis. You are in a lot of pain. You receive treatment from pain management, but they can no 
longer help you, so you need to see the requested provider as soon as possible. The Plan denied your request. 
The Plan says you must receive your care from a network provider. There are available providers in-network 
that may render the service requested. 
 
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 
an office visit (99204, 99214) to be provided by an out-of-network (OON) provider.