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

 
We decided that the Plan does not have to pay for Domiciliary services provided on August 27, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 Domiciliary services 
provided on August 27, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a computerized tomography (CT) scan on 
January 17, 2022. 
 
You asked the Plan to waive the coinsurance for a computerized tomography (CT) scan. You say that you feel 
as though the health plan keeps cutting your benefits and adding amounts. The Plan denied your request. The 
Plan says Per your Evidence of Coverage, the 20% Coinsurance is applied 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 up to $75 per day for a Computerized Tomography (CT) Scan. The total allowed amount of the 
computerized tomography (CT) scan is $213.55, resulting in a coinsurance amount of $42.71. 
 You have been asked to pay 20% coinsurance up to $75 per day for a computerized tomography (CT) Scan. A 
computerized tomography (CT) Scan falls within the Outpatient diagnostic tests and therapeutic services and 
supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a computerized 
tomography (CT) scan on January 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
August 19, 2021. 
 
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 the records submitted do not indicate that two separate services were performed/supported. 
 
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 the denied codes is: 
 
CPT 76641: 
 
Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete 
 
CPT 77066: 
 
Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral 
 
HCPCS G0279: 
 
Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066) 
 
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 the records provided to this reviewer 
only include one report for the services referenced above for date of service 08/19/2021, performed/reported at 
9:30 AM with accession number: 36492405.  
 
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 additional imaging services provided to the enrollee on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Special EEG Testing Procedures, Other EEG Testing 
Procedures provided on October 1, 2021. 
 
You asked the Plan to pay for Special EEG Testing Procedures, Other EEG Testing Procedures. The Plan 
denied your request. The Plan says Special EEG Testing Procedures, Other EEG Testing Procedures are 
experimental. 
 
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 pay for Special EEG Testing Procedures, Other EEG 
Testing Procedures. Our reviewer says that the requested Special EEG Testing Procedures, Other EEG Testing 
Procedures provided are not considered medically reasonable and necessary in this case. Our physician reviewer found that the review has determined that the services at issue 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 Special EEG Testing Procedures, Other EEG Testing Procedures have not been 
met. Therefore, we decided that the Plan does not have to pay for Special EEG Testing Procedures, Other EEG 
Testing Procedures provided on October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the caries risk assessment and documentation, with a finding 
of moderate risk (D0602) and oral hygiene instructions (D1330) provided January 17, 2022. 
 
You asked the Plan to pay for the caries risk assessment and oral hygiene instructions. You say that there was 
no reason for the dentist to check your tooth. The Plan denied your request. The Plan says these services are not 
covered under your 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 caries risk assessment and documentation, with a finding of moderate risk (D0602) and oral hygiene instructions 
(D1330) provided January 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the x-ray provided by a network provider on 
December 13, 2021. 
 
You asked the Plan to waive the deductible for the x-ray. You say that you believe the x-ray should be covered 
by your plan if medically necessary. You say the x-ray was medically necessary. The Plan denied your request. 
The Plan says you have been asked to pay the correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 deductible which applies to the x-ray. 
 
 
 
 
 The x-ray you asked the Plan to waive the deductible for falls within the Outpatient diagnostic tests and 
therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is a $300 deductible which applies to the x-ray. This cost sharing is a contractual 
obligation that had not been met at the time the x-ray was received on December 13, 2021. Therefore, we 
decided that the Plan does not have to waive the deductible for the x-ray provided by a network provider on 
December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Enteric Pathogens Panel provided to the enrollee on 
November 2, 2021. 
 
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 a review of the literature and clinical practice guidelines do not support the use of 
gastrointestinal pathogen panel tests with 6 to 11 pathogens except in the case of Clostridium difficile colitis 
suspicion. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a review of the literature and clinical practice guidelines does not support the use of gastrointestinal pathogen panel tests with 6 to 11 pathogens except in the case of Clostridium difficile colitis suspicion. C. 
difficile was not included on the gastrointestinal PCR panel. The review has determined that the services at 
issue in this case were 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Enteric Pathogens Panel provided to the enrollee on November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility provided on November 3, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility. You say that the rendering physician is a hospitalist 
physician with the group and depends upon the hospital staff to verify eligibility and to obtain the proper 
authorization from the patient's insurance company. The Plan denied your request. The Plan says the request is 
for services by a non-contracted provider for this date of service, and there is no referral letter from an in-
network physician. The Plan also says that the services were not medically necessary. 
 
 
 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 subsequent nursing facility provided on November 
3, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care provided on November 17, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a subsequent nursing facility care. You say that the rendering physician is a 
hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the 
proper authorization from the patient's insurance company. The Plan denied your request. The Plan says the 
request is for services by a non-contracted provider for the dates of service, and there is no referral letter from 
an in-network physician. The Plan also says that the services were not medically necessary. 
 
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 provided on 
November 17, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are needed to help the enrollee 
reach maximum function. The Plan denied your request. The Plan says that the enrollee no longer requires 
skilled inpatient needs as further gains can be made with outpatient therapy.  
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for continued SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. 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 the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has a chronic cough. There is 
no diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disease. There is no documented failure of other airway clearance measures, such as a flutter valve. The services are therefore not reasonable or medically 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 the enrollee is being treated for low 
back pain. The pain is sharp and shooting that localizes to the lumbar sacral junction. The documentation is 
lacking reasonably detailed and evidenced findings supportive of the spinal vertebral bodies as the 
overwhelming pain generators. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception to guidelines. Therefore, the requested Intracept 
intraosseous basivertebral nerve ablation at L5 and S1, 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 an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies provided on July 14, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code is 
not separately 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. We find that CPT code 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
additional supplies provided on July 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
December 31, 2021, to January 4, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 per day for days 1-6 of Inpatient hospital care.  
 
 
  You have been asked to pay a $650 copayment for 2 days of inpatient hospital care ($325 x 2 = $650). This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an inpatient hospital stay provided from December 31, 
2021, to January 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on November 
10, 2021. 
 You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 
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 the computed 
tomography (CT) scan provided on November 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory work provided by a network 
facility on January 20, 2022. 
 
You asked the Plan to waive the copayment for the laboratory work. You say that you did not have any medical 
procedure or visits on, or anywhere near this date of service. The Plan denied your request. The Plan says you 
have been asked to pay 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 $10 
copayment per day, per provider, for in-network Medicare-covered lab services.  
 
You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. The medical record shows 
the laboratory services were rendered on this date of service. 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 laboratory work provided by a network facility on January 
20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the inpatient hospital stay provided by a 
network facility from April 8, 2021, to April 10, 2021. 
 
 
 You asked the Plan to waive the cost sharing for the inpatient hospital stay. You say that you are disabled and 
unemployed. You say there is no reasonable expectation that you can pay this bill. 
 The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible which applies to the inpatient hospital stay and a 
$330 copayment per day, days 1-5, after you pay your $1,000 deductible.  
 
The inpatient hospital stay you asked the Plan to waive the cost sharing for falls within the Inpatient hospital 
care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$1,000 deductible which applies towards the inpatient hospital stay and a $330 copayment per day, days 1-5, 
after you pay your $1,000 deductible. See chart below. 
 
Dates of Service Service Allowed Amount Deductible/Copayment Member Liability 
April 8, 2021, to 
April 10, 2021 
Inpatient hospital 
stay 
$10,929.44 $1,000 $604.74  This is 
where you met the 
deductible amount. 
April 8, 2021, to 
April 10, 2021 
 $10,325.70  This 
is the remaining 
allowed amount 
after the deductible 
was applies. 
$330/per day $330 
Total    $934.74 
 
This cost sharing is a contractual obligation that had not been met at the time the inpatient hospital stay was 
received on April 8, 2021, to April 10, 2021. Therefore, we decided that the Plan does not have to waive the 
cost sharing for the inpatient hospital stay provided by a network facility from April 8, 2021, to April 10, 2021.