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

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on 
December 12, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that this should be covered. 
The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $250 
copayment per day for days 1 through 7. 
 
You have been asked to pay $250 copayment for inpatient hospital stay. Inpatient hospital stay falls within the 
Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient 
hospital stay provided on December 12, 2021.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the shoulder arthroscopy with debridement (29823). We decided that 
the Plan does not have to pay for the shoulder arthroscopy with rotator cuff repair (29827).  
 
  You asked the Plan to pay for the shoulder arthroscopy with debridement (29823) and shoulder arthroscopy 
with rotator cuff repair (29827). You say that the rotator cuff repair would qualify for a 22-modifier given the 
increased work required to repair the subscapularis and supraspinatus simultaneously. You say that the medical 
records should be reviewed to reprocess 29823 and 29827 for payment. The Plan says procedure codes 29823 
and 29827 are not supported by the medical records submitted. 
 
We decided that the Plan has to pay for the shoulder arthroscopy with debridement (29823).  
 
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 shoulder arthroscopy. Our reviewer says that the medical 
documentation supports the use of procedure code 29823. Our reviewer found that the provider documents 
more than three different areas of debridement between all the procedures performed. Therefore, we decided 
that the Plan has to pay for the shoulder arthroscopy with debridement (29823).  
 
We also decided that the Plan does not have to pay for the shoulder arthroscopy with rotator cuff repair 
(29827). 
 
Our reviewer says that the medical documentation does not support the use of procedure code 29827. The 
description of the billed code is different than the description of the procedure performed in the medical 
documentation. There is a more appropriate code to describe the procedure performed. Therefore, we decided 
that the Plan does not have to pay for the shoulder arthroscopy with rotator cuff repair (29827). 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive neuro-degenerative panel for dementia 
screening (81408, 81320) provided on January 3, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive neuro-degenerative panel for dementia screening. You say 
that the services should be covered as you disagree with the denial. The Plan denied your request. The Plan 
says the services denied correctly as they were non-emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan 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 comprehensive neuro-degenerative panel for 
dementia screening (81408, 81320) provided on January 3, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth visit with a specialty physician 
provided on March 17, 2022. 
 
You asked the Plan to waive the copayment for a telehealth visit with a specialty physician. You say that you 
weren't on the phone for very long with the provider, and don't feel like the charge is fair. The Plan denied your 
request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Physician/Practitioner services.  
 
You have been asked to pay a $35 copayment for a telehealth visit with a specialty physician. A telehealth visit 
with a specialty physician 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 telehealth visit with a specialty 
physician provided on March 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pluvicto. 
 
You asked the Plan to pre-approve Pluvicto. You say that you need this medication for the next step to prevent 
the tumor for growing. You also say that all other medications at this time have elapsed in their beneficial 
characteristics. The Plan denied your request. The Plan says in order for this drug to be covered, you must have 
been previously treated with Taxane-based chemotherapy. The Plan also says that this criterion has not been 
met, and there is no compendia support for using Pluvicto as an earlier-line therapy prior to Taxane-based 
therapy and no literature support was provided that would support this use prior to Taxane-therapy. 
 
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 Pluvicto. Our reviewer says that 
Pluvicto is not medically reasonable and necessary. Our physician reviewer found based on the guidelines of 
the National Comprehensive Cancer Network and the Medicare-approved major drug compendia, the only 
FDA-approved and medically accepted indication for Pluvicto is metastatic castration-resistant prostate cancer, 
Prostate-specific membrane antigen (PSMA) positive after treatment with androgen receptor pathway 
inhibition and Taxane-based chemotherapy. Our reviewer also found that the use is not supported by one of the 
major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services 
approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pluvicto have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Pluvicto.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening tuberculosis test (code 86480) provided on 
December 27, 2021. 
 You asked the Plan to pay for the screening tuberculosis test. You say that this claim should be processed. The 
Plan denied your request. The Plan says this screening test is not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the screening tuberculosis test, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for screening tuberculosis test (code 86480) provided on December 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF admission to be provided by an OON provider. 
 
You asked the Plan to pre-approve a skilled nursing facility admission. You say that you are appealing the 
denial of SNF admission. The Plan denied your request. The Plan says the authorization was denied because 
the request was for an out-of-network provider. 
 
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 
a skilled nursing facility admission to be provided by an OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services (ER) on April 07, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services (ER). You say that you should not 
have a copay because you were never seen by a doctor due to leaving after your blood pressure reading. The 
Plan denied your request. The Plan says the cost-sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for each Medicare-covered emergency room visit (if you are admitted to the hospital within 24 
hours for the same condition, the co-pay will be waived). 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 (ER). Emergency room services 
(ER) fall 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 (ER) on April 07, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 18, 2022, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. You say that the services were rendered in good faith and 
medically necessary. The rendering physician depends on the hospital staff to verify eligibility and to obtain the 
proper authorization from the enrollee's Plan. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on March 18, 2022, 
by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital admission and care provided 
from November 23, 2021, to November 24, 2021. 
 
You asked the Plan to pay for acute inpatient hospital admission and care. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the inpatient admission was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital admission and care. 
Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the record did not show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital admission and care have not been met. Therefore, we 
decided that the Plan does not have to pay for the acute inpatient hospital admission and care provided from 
November 23, 2021, to November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 an office visit provided on February 21, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on March 
29, 2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you had this procedure done 
before and it was covered. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for specialist services.  
 
The file shows that the Plan reprocessed the claim to reduce the copayment for the services from $100 to the 
correct amount of $45. Therefore, you are only responsible for the $45 copayment for the specialist visit. The 
specialist visit falls within the Physician/Practitioner Services, Including Doctor's 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 office visit provided on March 29, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance image (MRI), upper extremity 
(73221). 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee needs an MRI for their shoulder. The 
Plan denied your request. The Plan says the requested MRI is not medically necessary. 
 
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 the MRI. Our reviewer says that the 
requested MRI is not medically necessary. Our physician reviewer found there is no specific clinical rationale 
for the requested MRI of the right shoulder. The reviewer found that enrollee has not completed at least 6 
weeks of physician-directed treatment that includes medications, steroid injections and physical therapy. 
Therefore, the reviewer found that the requested MRI is not medically reasonable and 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 MRI have not been met.  
 
 
 
 
 Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance image (MRI), upper 
extremity (73221).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Vabysmo. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy. Our physician reviewer found the 
enrollee has a diagnosis of exudative age-related macular degeneration. The documentation does not support 
that the enrollee has tried and failed Bevacizumab. The documentation does not support that Bevacizumab 
would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does 
not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (85060) provided on December 29, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is 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. 
 
We find that payment CPT code 85060 is not supported in the medical record. Specifically, code 85060 is 
assigned a PC/TC indicator of 8. This means that no payment is recognized for code 85060 furnished to 
hospital outpatients or non-hospital patients. 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 
services (85060) provided on December 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an outpatient surgery provided from 
January 3, 2022, to March 9, 2022. 
 
You asked the Plan to waive the copayments for an outpatient surgery. You say that you were unaware there 
were copayments for outpatient procedures. The Plan denied your request. The Plan says the copayment 
applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for outpatient surgery.  
 
 
 
 
 
 
 You have been asked to pay a $300 copayment for an outpatient surgery. An outpatient surgery falls within the 
Outpatient Surgery Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayments for an outpatient surgery 
provided from January 3, 2022, to March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services provided on April 18, 
2022, by an OON provider. 
 
You asked the Plan to pay for transitional care management services. You say that you have received a denial 
for the service stating no precertification/authorization. The Plan denied your request. The Plan says the out-of-
network services were not authorized 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for transitional care management services provided on 
April 18, 2022, by an OON provider.