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

 
We decided that the Plan does not have to waive the copayment for an acute inpatient hospital stay provided 
from April 15, 2022, to April 23, 2022. 
 
You asked the Plan to waive the copayment for an acute inpatient hospital stay. You say that you are requesting 
an adjustment on the $1,000 copayment due to being on a fixed income and experiencing financial hardship. 
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 per day for days 1 to 5 and $0 copayment per day for days 6 to 90 for inpatient hospital care.  
 
 
  You have been asked to pay a copayment of $1,000 for days 1 to 5 of an acute inpatient hospital stay ($200 per 
day x 5 days = $1,000). 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 acute inpatient hospital stay provided from April 15, 2022, to 
April 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic imaging provided on March 30, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for diagnostic imaging. You say that the provider was told by the Plan representative 
that they were in-network. The Plan denied your request. The Plan says The enrollee must use network 
providers. If the enrollee receives unauthorized care from an out-of-network provider, we may deny coverage 
and the enrollee will be responsible for the entire cost. 
 
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 diagnostic imaging provided on March 30, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing provided December 1, 2021. 
 
You asked the Plan to pay for the PrismRA testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says medical documentation was missing to review the appeal. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the PrismRA test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the PrismRA testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the PrismRA testing provided December 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy (OT) services provided on June 28, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OT services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says 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 occupational therapy (OT) services provided on 
June 28, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on July 11, 
2022, to July 14, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that your healthcare manual 
says there is no charge for the first 20 days. 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 $295 
copayment for inpatient care per day, days 1 to 6. This inpatient hospital stay lasted 3 days, resulting in a 
copayment of $885 ($295 per day for 3 days = $885). 
 
You have been asked to pay $295 copayment per day for inpatient hospital care. This item/service falls within 
the per day, days 1 to 6 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 on July 11, 2022, to July 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. 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 follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when 
specific criteria are met. 
 
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 Orthovisc. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record indicates that another diagnosis 
is present. The record does not indicate that the enrollee has failed aspiration of the effusion. The elements of 
the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus panel testing provided October 18, 2021. 
 
You asked the Plan to pay for the Tempus panel testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing is not FDA-approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus panel testing is not FDA approved. 
Based on this information, we decided that Medicare rules for coverage of the Tempus panel testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the Tempus panel testing provided 
October 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 64719) provided to the 
enrollee on March 24, 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 the procedure is considered inclusive to CPT 64721. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure detailed that the 
ulnar nerve was identified distally in the area of Guyons canal. The ulnar neurovascular bundle was swept 
medially and the deep motor branch was decompressed and released in its entirety under direct visualization by 
release of the hypothenar fascia. Complete release of the deep motor branch was performed in this region. 
Neurolysis-neuroplasty appears inclusive to the primary/overall procedures already previously performed. Therefore, the records do not support that CPT 64719: neuroplasty and/or transposition, ulnar nerve- was a 
separate and distinct procedure from CPT 64721: neuroplasty and/or transposition; median nerve at the carpal 
tunnel. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure code 64719) provided to the enrollee on March 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services provided to the enrollee 
on March 4, 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 this service was not medically necessary. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the 
enrollee's presenting symptoms did not meet prudent layperson criteria for emergency care. The patient was 
transported by ambulance from an acute care hospital to a home setting after completion of inpatient hospital 
care. The documentation does not support that other means of transport (such as stretcher van, wheelchair van, 
taxi, private car, or other type of vehicle) were contraindicated for this member on March 4, 2022. The patient 
was stable at time of hospital discharge an alternate means of transportation would have been safe. The 
documentation does not support that the member needed the expertise, services and lifesaving and life-
sustaining equipment that only a fully-equipped ambulance can provide for safe transport on March 4, 
2022.The patient was stable and did not require any BLS or ALS monitoring or treatment during transport to 
the home. The documentation does not support that the ambulance transport on was medically reasonable and necessary for the enrollee on March 4, 2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance transportation services provided to the enrollee on March 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on January 27, 
2022. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that this copayment is too high and 
will cause a hardship. 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 $300 
copayment for ambulance services. 
 
You have been asked to pay a $300 copayment for an ambulance ride. 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 an ambulance ride 
provided on January 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on April 
28, 2022, to May 02, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you cannot afford this 
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 $1,400 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,400 copayment for inpatient hospital stay. 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 inpatient 
hospital stay provided on April 28, 2022, to May 02, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service May 10, 
2022. 
 
You asked the Plan to pay for procedure code 74176. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 74176 is bundled into payment for code 78815. 
 
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 74176 
is a column II code to column I code 78815. 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 74176 billed for date of service May 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Phesgo. 
 
You asked the Plan to pre-approve Phesgo. 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 pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Phesgo. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the 
coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Phesgo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Phesgo.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. 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 pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Tecentriq. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the 
coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat lift chair. 
 
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your 
request. The Plan says only items that are medically necessary may be approved. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 chair. Our reviewer says that the 
requested lift chair is not medically reasonable or necessary. Our physician reviewer found that the provided 
records do not document severe arthritis of the hip or a neuromuscular disease. The records do not document 
that a seat lift is included in the treating practitioner's course of treatment. The records do not document the seat 
lift is likely to effect improvement in your condition or arrest or retard deterioration in your condition. The 
provided records do not document you are completely incapable of standing from a chair in the home. You have the ability to ambulate. 
 
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 chair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power seat lift chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
September 17, 2021, to September 21, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was downgraded from 466 to 467.  
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 DRG 466 (REVISION OF HIP OR KNEE 
REPLACEMENT WITH MCC). 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 reviewer says that the services at issue in this case were not 
supported by the medical records. Our physician reviewer found that the review has determined that DRG 467 
REVISION OF HIP OR KNEE REPLACEMENT WITH CC is the appropriate DRG. The records did not 
support the use of secondary diagnosis code N17.0 - acute kidney failure with tubular necrosis. There was no 
evidence of acute tubular necrosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from September 17, 2021, to September 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76377 billed for date of service May 6, 2022. 
 
You asked the Plan to pay for procedure code 76377. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76377 is bundled into payment for code 78315. 
 
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 76377 
is a column II code to column I code 78315. 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 76377 billed for date of service May 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the biopsy of the uterus lining provided on 
June 03, 2022. 
 
You asked the Plan to waive the copayment for the biopsy of the uterus lining. You say that you dont know 
why insurance did not pay for this. 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 
$171.35 copayment for surgery or other services provided to you at an outpatient hospital. 
 
You have been asked to pay a $171.35 copayment for the biopsy of the uterus lining. This item/service falls 
within the surgery or other services provided to you at an outpatient hospital 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. The EOC says there is a $260 
copayment for surgery or services at an outpatient hospital. Since the allowed amount for the biopsy is $171.35, you are only responsible for the lesser amount. Therefore, we decided that the Plan does not have to 
waive the copayment for the biopsy of the uterus lining provided on June 03, 2022.