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

 
We decided that the Plan does not have to pre-approve a sooner right hip surgery date. 
 
You asked the Plan to pre-approve the sooner date. You say that it is not fair to have to suffer for an entire year 
and then wait again. The Plan denied your request. The Plan says expert testimony indicates that the enrollee's 
high surgery is not urgently needed. 
 
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 sooner date. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that detailed documentation is not evident regarding any examination findings of the right hip 
to corroborate this being an emergent procedure. Peer-reviewed literature does not support that an elective total 
hip replacement is an emergent surgery. 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 records do not support that the enrollee needs this surgery sooner than January 2023. 
 
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 sooner date have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sooner right hip surgery date.
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. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet all the requirements. 
 
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 has received physical and occupational therapy. The enrollee required 
supervision to contact guard assist with functional mobility and required varying assist with activities of daily 
living skills. 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. Our 
reviewer also found the enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Buprenorphine. 
 
You asked the Plan to pre-approve Buprenorphine. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Buprenorphine.  
 
Benefits for Buprenorphine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
March 2, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service March 2, 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 June 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 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 June 15, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2025), progressive lenses (V2781), and 
vision supply or accessory (V2797) received on April 19, 2022, by an out-of-network provider. 
 You asked the Plan to pay for deluxe frames, progressive lenses, and vision supply or accessory. You say that 
you want the Plan to pay for the services. The Plan denied your request. The Plan says services obtained from 
vendors outside of the Plan's network are not covered. 
 
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 services are obtained within the Plan's network. 
 
We looked at the file and the Plan's rules. The services at issue were obtained out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of deluxe frames, progressive lenses, and vision 
supply or accessory have not been met. Therefore, we decided that the Plan does not have to pay for deluxe 
frames (V2025), progressive lenses (V2781), and vision supply or accessory (V2797) received on April 19, 
2022, by an out-of-network 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 March 31, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
not feeling well, and your friend called 911. You also say that you refused to go the hospital because of 
COVID-19. The Plan denied your request. The Plan says the ambulance was called, and you refused to be 
transported to an emergency facility. The Plan also says that this service is not covered by Medicare. 
 
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 March 31, 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 March 31, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on June 13, 2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that the whole point of the 
colonoscopy is to find out if you have an issue. You also say that you do not understand what they are looking 
for if everything is perfect. 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 the outpatient hospital 
services, or outpatient surgery cost share will apply when a polyp removal or a biopsy is conducted during a 
preventive colorectal cancer screening. Your contract with the Plan also clearly says that enrollees must pay a 
$300 copayment for each Medicare-covered outpatient ambulatory surgical center visit. 
 
 
  You have been asked to pay a $300 copayment for a colonoscopy. This item/service falls within the Medicare-
covered outpatient ambulatory surgical center visit 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 colonoscopy provided on June 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 27, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We find that code 81479 is not supported in the medical record. Specifically, there is no documentation 
describing genetic testing on a sample collected on the date of service at issue. Therefore, we decided that the 
Plan does not have to pay for the laboratory services provided on April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Otezla. 
 
You asked the Plan to pre-approve Otezla. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Otezla.  
 
Benefits for Otezla may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on May 02, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. 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 $90 
copayment for each Medicare-covered emergency room visit. Emergency care refers to services that are 
furnished by a provider qualified to furnish emergency services, and needed to evaluate or stabilize an 
emergency medical condition. 
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
Emergency 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 emergency room 
services on May 02, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pegfilgrastim. 
 
You asked the Plan to pre-approve pegfilgrastim. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 pegfilgrastim. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there are no recurrent infections or 
bone marrow biopsy documenting adequate reserves. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pegfilgrastim have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pegfilgrastim.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on May 11, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you would like your copayment 
reimbursed. 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 $30 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for a specialist visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 specialist visit provided on May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on July 7, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you tried to get an 
appointment with your primary care physician (PCP), but no appointments were available. You say you were 
advised to go to urgent care, but you never would have gone if you knew there would be a $30 copayment. You 
say you would like the copayment waived or reduced to a $15 office visit. 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 $30 
copayment for urgent care facility visits.  
 
 
 
 
 You have been asked to pay a $30 copayment for the urgent care visit. This service falls within the urgently 
needed 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 an urgent care visit 
provided on July 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ekg) provided on 
July 13, 2022. 
 
You asked the Plan to waive the copayment for an electrocardiogram (ekg). You say that you have never had to 
pay for this on the same day with your physical for the last 30 years and should not have to now. 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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for an electrocardiogram (ekg). This item/service 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 copayment for an electrocardiogram (ekg) provided on July 13, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on May 4, 2021, to May 8, 2021, at 
the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says that the secondary diagnosis was not supported. 
 
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 J96.01, defined as acute respiratory failure with 
hypoxia. 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 inpatient hospital services at the 
DRG originally billed. Our physician reviewer found that the enrollee was transferred to the hospital with 
moderate respiratory distress and recurrent episodes of significant hemoptysis. Upon arrival, the enrollee was 
short of breath with an oxygen sat of 85% on room air. On admission, the enrollee was coughing incessantly 
and was having difficulty because of his coughing fits. He had large amounts of productive sputum with frank 
hemoptysis. At the time of admission, the enrollee was ill-appearing, tachycardic, in mild respiratory distress, 
with occasional faint wheezing, rhonchi, and diffuse rales. The enrollee was diagnosed with acute hypoxemic 
respiratory failure. The pulmonologist determined that the enrollee had chronic atypical tuberculosis infection, 
bronchiectasis, chronic obstructive pulmonary disease (COPD), and acute hypoxic respiratory failure. The 
clinical documentation supports the diagnosis of J96.01, acute respiratory failure with hypoxia. The enrollee 
had hypoxemia, as well as signs and symptoms of acute respiratory distress. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on May 4, 2021, to May 8, 2021, at the Diagnosis Related Group (DRG) originally 
billed.  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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency service ambulance transport and 
ground mileage provided on November 29, 2021. 
 
You asked the Plan to waive the copayment for emergency service ambulance transport and ground mileage. 
You say that this was coronavirus (COVID-19) related. 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 $265 
copayment for the date of service regardless of the number of trips for emergency ground ambulance. 
 
You have been asked to pay a $265 copayment for emergency service ambulance transport and ground 
mileage. This item/service falls within the the date of service regardless of the number of trips for emergency 
ground ambulance 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 emergency service 
ambulance transport and ground mileage provided on November 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
spinal canal lumbar provided on July 21, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI) of the spinal canal 
lumbar. You say that you do not feel you should have to pay for a procedure that was the wrong procedure due 
to an incorrect order from a doctor. 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 $200 
copayment for each advanced imaging services (MRI). 
 
You have been asked to pay a $200 copayment for a magnetic resonance imaging (MRI) of the spinal canal 
lumbar. This item/service falls within the each advanced imaging services (MRI) 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 magnetic resonance imaging (MRI) of the spinal canal lumbar 
provided on July 21, 2022.