Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on October 
11, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you were under the 
impression there was no copayment for a follow-up appointment, so you are not paying this bill. 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 $40 
copayment for physician/practitioner services, including doctors office visitp. 
 
You have been asked to pay a $40 copayment for specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visitp 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 specialist office visit provided on October 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for laboratory services provided on January 
21, 2022. 
 
You asked the Plan to waive the coinsurance for laboratory services. You say that you disagree with the 
copayment. 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 20% 
coinsurance for outpatient diagnostic tests/lab services.  
 
You have been asked to pay a 20% coinsurance for laboratory services. The total allowed amount for the 
laboratory services is $1,635.90. You are being asked to pay $327.18 ($1,635.90 x 20% = $327.18). This 
item/service falls within the outpatient diagnostic tests/lab 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 laboratory services provided on January 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 4, 2022, to 
April 30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the claim at issue was not billed with an admission 
date for the first date in 2022 as required. Based on this information, we find that the Medicare rules for 
payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from April 4, 2022, to April 30, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing care (procedure code 99310) provided to the enrollee 
on January 27, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is a more appropriate code to use in this case. 
 
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 99310 is "Subsequent nursing facility care, per day, for 
the evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using total time on the date of the encounter for code 
selection, 45 minutes must be met or exceeded." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records submitted 
indicates patient was seen in outpatient, at her assisted living facility. Therefore, CPT 93310 would not be the appropriate CPT code to submit for reimbursement consideration for this encounter. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for nursing care (procedure code 99310) provided to the enrollee on January 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis injections provided on 
October 25, 2022. 
 
You asked the Plan to waive the copayment for arthrocentesis injections. You say that you are on a fixed 
income and cannot afford the copayment. 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 $300 
copayment for surgery services. 
 
You have been asked to pay a $300 copayment for arthrocentesis injections. This item/service falls within the 
surgery 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. However, since the allowed amount is less than the standard copayment, you only owe $281.96. 
Therefore, we decided that the Plan does not have to waive the copayment for arthrocentesis injections 
provided on October 25, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 0089U. We decided that the Plan does not have to pay 
for procedure code 81345.  
 
You asked the Plan to pay for laboratory services (0089U and 81345) provided on May 3, 2022. You say that 
this testing was necessary and is covered by Medicare. The Plan says that the payment for these services is 
bundled into the payment for other services. 
 
We decided that the Plan has to pay for procedure code 0089U.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan states that the payment for this service is bundled into the 
payment for another service provided on this same date. However, the Plan does not clarify which service 
includes code 0089U. In addition, the documentation provided does not include any evidence that any services 
other than those at issue were provided for the enrollee on this date. The Plans denial is not substantiated in 
this case. Therefore, we decided that the Plan has to pay for procedure code 0089U.  
 
We also decided that the Plan does not have to pay for procedure code 81345. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of nivolumab and ipilumumab. 
 
You asked the Plan to pre-approve nivolumab and ipilumumab. You say that the enrollee has disease 
progression and needs treatment with these drugs. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 nivolumab and ipilumumab. Our 
reviewer says that the enrollee does not meet criteria for this drug combination. Our physician reviewer found 
nivolumab and ipilumumab are not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. 
These drugs are not supported by one of the major drug compendia or by clinical research appearing in a 
Medicare-approved medical journal. Per guidelines, if there was progression on a PD-1/PD-L1 inhibitor, using 
a PD-1/PD-L1 inhibitor is not recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nivolumab and ipilumumab have not been met. Therefore, we decided that the 
Plan does not have to pre-approve use of nivolumab and ipilumumab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the device will manage symptoms that 
lead to repeat hospitalizations. The Plan denied your request. The Plan says the clinical effectiveness has not 
been demonstrated in peer-reviewed literature. 
 
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 requested services Our physician 
reviewer found that the enrollee has recurrent congestive heart failure (CHF). The clinical study on which the 
Food and Drug Administration (FDA) approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness. Nonetheless, there 
remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing 
the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not 
be considered medically appropriate and necessary in this enrollees clinical management. 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says this cost sharing was charged correctly. Per your 
Evidence of Coverage, if the Plan determines that a less expensive alternate procedure, service, or course of 
treatment can be performed in place of a proposed treatment to correct a dental condition; and if the alternate 
treatment will produce a professionally satisfactory result, then the maximum, then the Plan will charge for the 
less expensive treatment. 
 
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 50% 
coinsurance for the dental services.  
 
You have been asked to pay a 50% coinsurance for the dental services. This item/service falls within the dental 
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 pay for the dental services on March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for external electrocardiographic recording provided on October 
11, 2022. 
 
You asked the Plan to pay for external electrocardiographic recording. You say that you are appealing the 
claim payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for external 
electrocardiographic recording provided on October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on December 31, 
2021. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary or rest home 
visit provided on December 31, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee lives alone in an upstairs apartment, the 
only supportive family is an elderly father who is unable to assist them at this level of functioning that they are 
at now. This would allow the enrollee to become much stronger and return to the level of independency that 
they had prior to her being admitting into the hospital. The Plan denied your request. The Plan says the request 
is not a covered benefit, The services the enrollee require are called custodial care. Custodial care helps you with daily needs such as dressing, bathing, getting in and out of bed, going to the bathroom, and eating. 
Custodial care is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4305 and A4223 provided from July 29, 
2022, to August 4, 2022. 
 
You asked the Plan to pay for the billed services. You say that home infusion services were provided. The Plan 
denied your request. The Plan says the services are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that CPT code A4305 is non-covered because it does not meet the Medicare definition of durable 
medical equipment. Supplies, such as code A4223, used with disposable drug delivery systems are also non-
covered items. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A4305 and 
A4223 provided from July 29, 2022, to August 4, 2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to cover the computed tomography (CT) scan. We decided that the Plan does 
not have to cover the computed tomography (CT) scan.  
 
You asked the Plan to cover a computed tomography (CT) scan (75571) provided on September 7, 2022.. You 
say that you believed this was authorized. The Plan says that this was not authorized, and the allowed amount is 
less than your copayment would be. 
 
We decided that the Plan has to cover the computed tomography (CT) scan.  
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The computed tomography (CT) scan at issue was provided by a contract provider. The file does not show that 
the Plan provided notice that the computed tomography (CT) scan would not be covered. Under Medicare 
rules, this means the computed tomography (CT) scan is considered approved by the Plan. Therefore, we 
decided that the Plan has to cover the computed tomography (CT) scan.  
 
We also decided that the Plan does not have to waive the copayment for the computed tomography (CT) 
scan. 
 
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 $350 
copayment for outpatient diagnostic services such as computed tomography scans. 
 
You are responsible for a $250 copayment for the computed tomography (CT) scan because the total amount 
you paid for this service is less than your contractual copayment. 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 cover the 
computed tomography (CT) scan. 
 
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: 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 the IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility, home with home health and home physical therapy, or 
home with outpatient therapy. 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted to an acute hospital with polycythemia, uterine cancer, 
adrenal and lung metastasis, a urinary tract infection, and bilateral pleural effusions requiring thoracentesis. At 
the current level of functional mobility and activities of daily living, the enrollee does not need intensive 
therapies consisting of at least three hours of therapy per day at least five days per week with multidisciplinary 
approach in an IRF. The document does not support necessity for admission to an IRF due to lack of medical or 
rehabilitation complexity and acute rehabilitation nursing needs. 
 
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.