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

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is medically stable and does not need medical monitoring by a rehabilitation 
doctor. 
 
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 that the enrollee does not meet the coverage criteria for this admission. The enrollee is medically stable, and does not need close supervision three times per week (at a minimum) for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. There are no acute nursing 
needs identified or documented. The enrollee does not need three hours a day and five days a week of 
therapies. There is a lack of medical complexity. Rehab needs can be safely provided in an alternate and lower 
intensity setting, such as in the assisted living facility with continued 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on March 30, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim has not been processed by the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has the Plan 
confirmed they have not received an Explanation of Benefits (EOB) from the primary insurer for this claim. As 
the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the anesthesia 
services rendered on March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on May 22, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that you rely on the facility to obtain 
this information when they ask you to see patients in their location. The Plan denied your request. The Plan 
says this provider is not a network provider with the Plan. The Plan also says that they have also determined 
that these services are not urgent or emergent, nor were they approved in advance. 
 
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 domiciliary or rest home visit provided on May 
22, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 12, 
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 12 months of the date of service is the timely filing limit for claim submission. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until [enter date the claim was filed]. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a shoulder orthosis (sling) provided to the 
enrollee on March 14, 2022. 
 
You asked the Plan to waive the coinsurance for the shoulder sling. You say that the sling was inadequate. The 
Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for durable medical equipment (DME).  
 
The enrollee has been asked to pay $17.72, which is 20% of the allowed amount for the shoulder sling ($88.63 
allowed amount x 20% coinsurance = $17.72). The shoulder sling falls within the Durable Medical Equipment 
(DME) and Related Supplies benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
a shoulder orthosis (sling) provided to the enrollee on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility services provided on January 4, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility services. You say that you have provided the medical records 
so the claim can be reprocessed. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no approved authorization. 
  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 the nursing facility services provided on January 
4, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an omalizumab injection provided on 
March 21, 2022. 
 
You asked the Plan to reduce the coinsurance for the injection. You say that you feel you should not be paying 
this much for your allergy shots. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay $450.12, which is 20% of the allowed amount for the injection ($2,250.60 allowed 
amount x 20% coinsurance = $450.12). The injection falls within the Medicare Part B Prescription Drugs 
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 reduce the coinsurance for an omalizumab injection 
provided on March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on August 06, 2021. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. 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 $55 
copayment for out-of-network specialist office for each Medicare-covered other health care professional 
service. Covered services include consultation, diagnosis, and treatment by a specialist.   
 
You have been asked to pay a $55 copayment for office visit. Office 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 office visit on August 06, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
November 9, 2021, to November 14, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that the bill is too high and you do 
not understand why. 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 $335 per 
day for days 1-5 and $0 per day for additional days for each inpatient admission.  
 
The file shows that you were in the hospital from November 9, 2021, to November 14, 2021. The file also 
shows that the Plan reprocessed the claim and removed to $362 charge for the private room. Therefore, you 
have been asked to pay $335 per day for days 1-5 of inpatient care. The total for your stay is $1,675 ($335 
copayment x 5 days = $1,675). The inpatient care 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 care provided from November 9, 2021, to 
November 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract surgery rendered on March 7, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures 
performed on different anatomical sites. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required 
anatomical modifier. 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 pay for the cataract surgery rendered 
on March 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical decompression of forearm and/or wrist (25025) 
provided on February 6, 2022. 
 You asked the Plan to pay for a decompression of forearm and/or wrist. You say that you have provided 
medical records to support the services billed. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
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 25025 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 a 
decompression of forearm and/or wrist have not been met. Therefore, we decided that the Plan does not have to 
pay for a surgical decompression of forearm and/or wrist (25025) provided on February 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided to the enrollee on January 11, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was another plan as primary. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has The plan has directed the claim to be submitted to the primary plan.. As the secondary insurer, the Plan cannot be held 
responsible for the servcies until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for pathology services provided to the enrollee on January 11, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a colonoscopy provided on April 28, 2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you should not be charged this 
copayment because this was just a colonoscopy and was not diagnostic. The Plan denied your request. The Plan 
says that this was a diagnostic colonoscopy due to history of polyps and the copayment applied was correct. 
 
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 no coinsurance, copayment, or deductible for a Medicare-covered 
colorectal cancer screening exam. The Evidence of Coverage (EOC) does not specify that you cannot have a 
colorectal cancer screening if you have a history of polyps. 
 
The Plan says you must pay a $250 copayment for a colonoscopy. Based on the Plan contract, however, you 
cannot be asked to pay for a screening colonoscopy. Therefore, we decided that the Plan has to waive the 
copayment for a colonoscopy provided on April 28, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73020 billed for date of service April 12, 
2022. 
 
You asked the Plan to pay for procedure code 73020. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 73020 is bundled into payment for code 73030. 
 
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 73020 
is a column II code to column I code 73030. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 73020 billed for date of service April 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on 
January 3, 2022, and January 4, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the care that the enrollee required was 
medically necessary and appropriately administered as outlined in the medical records. The Plan denied your 
request. The Plan says these services required prior authorization. 
 
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 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 that the enrollee presented to the hospital for a planned nonemergent femoral 
thrombectomy and common femoral artery endarterectomy. She tolerated the procedure without complication 
or instability. She remained hemodynamically stable, tolerating diet, with pain controlled, and able to ambulate 
soon afterward. There was no indication that the patient would have required hospital services following this 
surgery that would likely cross 2 midnights based on the documentation provided.  
 
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 care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee on January 3, 2022, and 
January 4, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services rendered from June 21, 2021, to June 23, 
2021. 
 
You asked the Plan to pay for these services. You say that the inpatient level of care was approved. The Plan 
denied your request. The Plan says that the claim was processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan autoforwarded the case to MAXIMUS without a clear denial reason for 
the overpayment recoupment. There is no documentation to support that the claim was processed correctly per 
Medicare rules. Therefore, we decided that the Plan has to pay for the inpatient hospital services rendered from 
June 21, 2021, to June 23, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and the debridement of nails provided on April 
20, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and the debridement of nails. You say that at the time of service 
there was an authorization. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved authorization. Also, the service 
rendered was not urgent or emergent. 
 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 and the debridement of nails 
provided on April 20, 2021, by an out-of-network (OON) provider.