Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve major joint or bursa injection or aspiration without 
ultrasound guidance (20610) Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose 
(J7324). 
 
You asked the Plan to pre-approve injection services. You say that the enrollee has right hip pain and is 
attempting to get a right hip bursa hyaluronate injection, not a knee injection. The Plan denied your request. 
The Plan says the requested service is for a hip injection and does not meet medical requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 
 
 We looked at the file, and Medicare rules. The Pharmacy Coverage Policy specifically says that safety and 
effectiveness of use in joints other than the knee has not been established. Based on this information, we 
decided that Medicare rules for coverage of injection services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve major joint or bursa injection or aspiration without ultrasound guidance 
(20610) Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose (J7324).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management services (procedure code 62320) provided 
to the enrollee on January 18, 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 is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code 62320 is not covered. 
 
The procedure code used for these services in this case is not covered at this time. 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 pain management services (procedure code 62320) provided to the enrollee on 
January 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital stay provided from 
January 5, 2022, to February 18, 2022. 
 
You asked the Plan to waive the coinsurance for inpatient hospital stay. You say that you were not able to get 
the care you needed at home, so you had to be inpatient. The Plan denied your request. The Plan says the 
coinsurance applied is less than the standard 10% coinsurance because you met your maximum out-of-pocket. 
 
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 10% 
coinsurance for each Medicare covered hospital admission/stay. 
 
 You have been asked to pay $1585.97, which is less than the standard 10% coinsurance for the inpatient stay 
because you met your maximum out of pocket. 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 coinsurance for inpatient hospital stay provided 
from January 5, 2022, to February 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
November 10, 2021, to November 18, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you were never told about 
the copayments so they 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 each day for days 1 to 7 for Medicare-covered hospital care. $0 copayment for additional Medicare-
covered days.  
 
 
 You have been asked to pay a total of $1750 copayment for your 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 from November 10, 2021, to November 18, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on February 7, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you think it should be covered 
because originally you were told your wrist wasn't broken but then it turned out it was. 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 $110 
copayment for Medicare-covered emergency room visits.  
 
You have been asked to pay $110 copayment for the ER visit. ER visits 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 the ER visit provided on February 7, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided to the enrollee on October 26, 2021 to 
October 27, 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 that the enrollee's date of death was October 2, 2021. 
 
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 has not substantiated their denial. This denial is not valid. There is an 
official certificate of death, signed and certified by a physician, for October 28, 2021. Additionally, there are 
medical records showing the services occurred on October 26, 2021 and October 27, 2021, making it 
impossible for the enrollee to have died on October 2, 2021. Therefore, we decided that the Plan has to pay for 
anesthesia services provided to the enrollee on October 26, 2021 to October 27, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from December 28, 2021, to January 18, 2022. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you had to stay an extra day due to 
a snowstorm. 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 $0 per 
day for days 1-20 and $184 per day for days 21-100 for each benefit period. 
 
Dates of Service Benefit Days Copayment 
December 28, 2021  January 16, 2022 1-20 $0/day 
January 17, 2022 21 $184/day 
Total:  $184 You have been asked to pay $184 for day 21 of the SNF care. The SNF care falls within the Skilled Nursing 
Facility (SNF) 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 skilled nursing 
facility (SNF) care provided from December 28, 2021, to January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on February 8, 
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 code is not eligible for payment. 
 
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, the CPT Code Manual definition of code 00812 is "Anesthesia for lower intestinal endoscopic 
procedures, endoscope introduced distal to duodenum; screening colonoscopy." 
 
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 the review has determined that the the 
records did not support the use of CPT 00812 in this case. 
 
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 anesthesia services provided to the enrollee on February 8, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the deductible and coinsurance for an office visit and skin biopsy 
provided on February 1, 2022. 
 
You asked the Plan to waive the deductible and coinsurance for an office visit and skin biopsy. You say that 
you should not be responsible for this charge. The Plan denied your request. The Plan says that the cost share 
applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan does not list a deductible that would apply to any service. Your contract with the Plan 
clearly says that enrollees pay $0 for provider and professional services a PCPs office or Specialists office. 
 
The Plan says you must pay $11.93 coinsurance and $178.70 deductible for an office visit and skin biopsy. 
Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment for the office visit 
and skin biopsy. Therefore, we decided that the Plan has to waive the deductible and coinsurance for an office 
visit and skin biopsy provided on February 1, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a therapeutic injection provided on 
October 13, 2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you believe this charge should be 
covered. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Medicare-covered Part B chemotherapy, prescription drugs and immunizations.  
 
 
 
 
 
 You have been asked to pay $1,980 which is 20% of the allowed amount for an injection. The allowed amount 
is $9,900 (20% x 9,900= $1,980). Injections fall 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 waive the coinsurance for a therapeutic injection provided on October 
13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a therapeutic injection provided on January 
21, 2022. 
 
You asked the Plan to waive the copayment for an injection. You say that you should have been told about this 
cost share. You also say that you feel that you should not be responsible to pay it. 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 $325 
copayment for outpatient surgery at an outpatient hospital.  
 
You have been asked to pay a $325 copayment for an injection. An injection 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 copayment for a therapeutic injection provided on January 21, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mental health visit provided on January 13, 
2022. 
 
You asked the Plan to waive the copayment for mental health visit. You say that you thought the copayment 
was only $30 and you will not pay more than that. 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 $55 
copayment for each out of network Medicare covered individual or group therapy visit.  
 
You have been asked to pay $55 copayment for a mental health visit. Mental health visits fall within the 
Outpatient mental health 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 a mental 
health visit provided on January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chiropractic visit provided on January 
10, 2022. 
 
You asked the Plan to waive the copayment for the chiropractic visit. You say that you would like the 
copayment reversed because you thought you wouldn't have to pay anything. 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 $50 
copayment for out of network chiropractic visits.  
 
You have been asked to pay $39.74 which is less than the standard $50 copayment for out of network 
chiropractic services. Chiropractic visits fall within the Chiropractic 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 the chiropractic visit provided on January 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan provided on February 8, 
2022. 
 
You asked the Plan to waive the copayment for a duplex scan. You say that you feel the plan should cover 
more of the charges. 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 $105 
copayment for Medicare covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
You have been asked to pay $105 copayment for the duplex scan. Duplex scans fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for a duplex scan provided on February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 17, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
 
 
 
 We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on October 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 20, 2021.
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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's needs can be met at a lower level of care such as a skilled nursing facility. 
 
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 based on the medical records provided there is inadequate documentation that the 
complexity of the patient's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no up to date reports of any medical 
conditions which require a physicians evaluation three or more times per week. The patient has required 
physical therapy and occupational therapy services, but the medical records provided do not clarify why the 
patient requires an intensive inpatient rehabilitation therapy program. The provided records do not explain why 
the intensive inpatient rehabilitation therapy program is necessary and why therapy at a lower level of care such 
as in a skilled nursing facility is not appropriate for the patient. There is no clear (up to date) documentation 
that the patient requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation 
facility. Records do not clarify that treatment at the skilled nursing facility level is not appropriate in this case.   
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve molecular pathology procedure (81403) CALR 
(calreticulin) (eg, myeloproliferative disorders), gene analysis, common variants in exon 9 (81219) JAK2 
(Janus kinase 2) V617F gene analysis (81270). 
 
You asked the Plan to pre-approve the genetic testing. You say that you are appealing the denied pre-
authorization for genetic testing. The Plan denied your request. The Plan says the request is not medically 
necessary as the records do not support that the criteria has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve molecular pathology procedure (81403) CALR (calreticulin) (eg, myeloproliferative disorders), gene 
analysis, common variants in exon 9 (81219) JAK2 (Janus kinase 2) V617F gene analysis (81270).