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

 
We decided that the Plan does not have to pay for laboratory drug testing provided on November 29, 2022. 
 
You asked the Plan to pay for laboratory drug testing. You say that this was medically necessary and should be 
covered. 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 laboratory drug testing 
provided on November 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service October 18, 
2022. 
 You asked the Plan to pay for procedure code 86077. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service October 18, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that a SNF admission is medically necessary. The Plan 
denied your request. The Plan says the member does not meet the criteria for a SNF admission. 
 
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 have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
However, the enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 
setting. Criteria for a SNF admission has not been met. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the esophagus x-ray provided on November 
14, 2022. 
 
You asked the Plan to waive the deductible for the x-ray. You say that you do not understand why this claim 
was not paid in full. 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. Your 
contract with the Plan says that there is a $1,000 deductible which applies to in-network and out-of-network 
outpatient diagnostic x-rays. Your Plan contract also clearly says that you must pay a $15 copayment after 
meeting your deductible for in-network x-rays. 
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible which applies to in-network and out-of-network outpatient diagnostic 
x-rays. This cost sharing is a contractual obligation that had not been met at the time the x-ray was received on 
November 14, 2022. Therefore, we decided that the Plan does not have to waive the deductible for the 
esophagus x-ray provided on November 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care from 
March 17, 2023, forward. 
 You asked the Plan to pre-approve continued SNF care. You say that the enrollee is not strong enough to 
discharge home. The Plan denied your request. The Plan says records did not indicate that the member has met 
the plans coverage criteria for SNF care. 
 
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 continued 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 that 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 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care from March 17, 2023, forward.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 
03, 2022. 
 
You asked the Plan to waive the copayment for ambulance 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 $295 
copayment for ambulance services. 
 
You have been asked to pay a $295 copayment for ambulance services. This item/service falls within the 
ambulance 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 ambulance services 
provided on October 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided on August 
08, 2022. 
 
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you disagree with the 
coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for outpatient surgery/surgery performed at an outpatient hospital facility. 
 
You have been asked to pay 20% coinsurance for an outpatient surgery. This item/service falls within the 
outpatient surgery/surgery performed at an outpatient hospital facility 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 an outpatient surgery provided on August 08, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on September 15, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you took the medicine that was given to 
you in the hospital. The Plan denied your request. The Plan says self-administered drugs do not fall under Part 
B 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 pay for self-administered drugs provided 
on September 15, 2022.  
 
Benefits for self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9946). 
 
You asked the Plan to pre-approve the dental services. 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 do 
not fall within your dental 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 pre-approve an 
occlusal guard (D9946).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service August 19, 
2022. 
 You asked the Plan to pay for procedure code 86077. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service August 19, 2022.
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 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 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on November 07, 2022. 
 
You asked the Plan to pay for the mental health services. You say that you were informed that the provider was 
in-network. 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 the mental health 
services provided on November 07, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic vascular testing provided on December 01, 2022. 
 
You asked the Plan to pay for diagnostic vascular testing. You say that this was medically necessary and should 
be covered. 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 diagnostic vascular 
testing provided on December 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a false tooth and crown (D6242, D6752). 
 
You asked the Plan to pre-approve the dental services. 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 do 
not fall within your dental 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 pre-approve a 
false tooth and crown (D6242, D6752).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the diagnostic colonoscopy and the 
anesthesia services provided on November 29, 2022. 
 
You asked the Plan to waive the cost sharing for the colonoscopy and the anesthesia services. You say that you 
do not think you should be responsible for this cost sharing. 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. Your 
contract with the Plan says that you must pay the full cost for most covered services until you have paid the 
$400 deductible, and the deductible applies to all in and out-of-network services besides emergency services, 
all Medicare zero-cost preventative services, and urgent care services. Your contract with the Plan also says 
that you must pay a 2% coinsurance of the approved amount, after you meet the annual deductible, for in and 
out-of-network outpatient surgery services. 
 
You have been asked to pay a cost share of $143.90 for the colonoscopy ($108.49 allowed amount x .02 = 
$2.17 rounded up) ($2.17 coinsurance + $141.73 deductible = $143.90). This item/service falls within the 
outpatient surgery, including services provided at a hospital outpatient facilities and ambulatory surgical 
centers benefit category. You have also been asked to pay a $152.78 deductible for the anesthesia services. 
These items/services fall 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 $400 
deductible which applies to outpatient surgery, including services provided at a hospital outpatient facilities and 
ambulatory surgical centers, and outpatient diagnostic tests and therapeutic services and supplies. This cost 
sharing is a contractual obligation that had not been met at the time the colonoscopy and the anesthesia services 
were provided on November 29, 2022. Therefore, we decided that the Plan does not have to waive the cost 
sharing for the diagnostic colonoscopy and the anesthesia services provided on November 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the CT scan is to follow 
up on the enrollee's pulmonary infiltrate, pulmonary nodules and adenopathy in abdomen that may warrant 
therapy. The Plan denied your request. The Plan says a CT scan of the abdomen and pelvis is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the abdomen and pelvis. 
Our reviewer says that the requested CT scan of the abdomen and pelvis is not medically necessary. Our 
physician reviewer found that the clinical notes state a CT scan would be ordered if flow cytometry indicated a 
lymphoproliferative disorder. However, the flow cytometry and pathology review were not submitted for 
review. Therefore, there is no clear indication for the CT scan of the abdomen and pelvis. 
 
   
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 CT scan of the abdomen and pelvis. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on June 22, 2022. 
 
You asked the Plan to pay for the drug testing. You say that you were not aware that prior authorization was 
required. 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 the drug testing 
provided on June 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IRF stay provided from November 23, 
2022, to December 3, 2022. 
 
You asked the Plan to waive the copayment for an IRF stay. You say that you feel the IRF copayment should 
be waived due to the extraordinary amount. 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 $350 per 
day for days 1 to 5 and $0 after day 5 for each acute rehabilitation hospital admission.  
 
 You have been asked to pay a $1,750 copayment for an IRF stay ($350 per day x 5 days = $1,750). This 
item/service 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 an IRF stay provided from November 23, 2022, to December 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the AED vest provided on October 1, 
2022. 
 
You asked the Plan to waive the coinsurance for the AED vest. You say that you were unaware of the cost. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment and related supplies.  You have been asked to pay $540.99 coinsurance, which is 20% of the allowed amount for the AED vest 
($2,704.94 allowed amount x 20% = $540.99). This item/service falls within the durable medical equipment 
and related 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 the automatic 
external defibrillator (AED) vest provided on October 1, 2022.