Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for rehabilitation services provided on 
December 27, 2021. 
 
You asked the Plan to waive the copayment for rehabilitation services. You say that you have a limited income 
and cannot afford to pay this. The Plan denied your request. The Plan says the cost share has been applied 
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 $35 
copayment for rehabilitation services.  
 
You have been asked to pay a $35 copayment for rehabilitation services. Rehabilitation services fall within the 
Outpatient Rehabilitation 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 
rehabilitation services provided on December 27, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from March 17, 2022, 
to March 31, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that youre not sure what the charges are 
for. 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 $0 
copayment each day for Medicare-covered days 1 to 20. $50 copayment each day for Medicare covered days 
21 to 70.  
 
 
 
 You have been asked to pay $500 ($50 x 10 days for days March 21-March 31, 2022) copayment for SNF care. 
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 SNF care provided from March 17, 2022, to March 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on December 16, 2021. 
 
You asked the Plan to waive the copayment for ambulance. 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 $250 
copayment for each one-way Medicare-covered ground trip. Covered ambulance services include fixed wing, 
rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care only if 
they are furnished to a member whose medical condition is such that other means of transportation could 
endanger the persons health or if authorized by the plan.  
 
 
 
 
 You have been asked to pay a $250 copayment for ambulance. Ambulance 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 on December 16, 
2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for tissue exam by a pathologist provided on January 11, 2022. 
 
You asked the Plan to pay for tissue exam by a pathologist. You say that you had no control whatsoever as to 
what happened to the tissue sample after it was taken by your physician. You also say that your physician is an 
in-network physician, and you do not think it is proper for you to question where he sends the samples. The 
Plan denied your request. The Plan says that it looks like you received care from a provider outside the plan 
network, so the care you received with them is not covered by your plan. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for tissue exam by a pathologist by a contract provider. The file does not show that the Plan 
provided notice that tissue exam by a pathologist would not be covered. Under Medicare rules, this means 
tissue exam by a pathologist is considered approved by the Plan. Therefore, we decided that the Plan has to pay 
for tissue exam by a pathologist provided on January 11, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code 80307 and G0481) 
provided to the enrollee on February 9, 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 documentation does not support that eight or more drug classes were tested. 
 
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 the denied codes is: 
 
CPT 80307: 
 
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument 
chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service G0481: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed 
 
We find that these codes are not supported in the medical record, as only seven drug classes were tested. 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 drug testing services (procedure code 80307 and G0481) 
provided to the enrollee on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit (99336) provided on March 4, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the rest home visi. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a rest home visit (99336) provided on March 4, 
2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for bone length studies (X-rays) provided on 
March 16, 2022. 
 
You asked the Plan to waive the copayment for the X-rays. You say that the procedure was done and read 
incorrectly. 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 an $85 
copayment for basic radiological services at an outpatient hospital.  
 
You have been asked to pay an $85 copayment for the X-rays. The X-rays 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 bone length studies (X-rays) provided on March 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy on April 08, 2022. 
 
You asked the Plan to waive the copayment for colonoscopy. 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 $400 
copayment for diagnostic colonoscopy at outpatient hospital. Covered services include but are not limited to 
laboratory and diagnostic tests billed by the hospital.  
 
You have been asked to pay a $400 copayment for colonoscopy. Colonoscopy falls within the Outpatient 
hospital 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 colonoscopy on 
April 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit and a 
comprehensive hearing test provided on May 20, 2022. 
 
You asked the Plan to waive the copayments for the specialist visit and hearing test. You say that the hearing 
test should be free. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for each diagnostic hearing exam. 
 
Your contract with the Plan also clearly says that you must pay a $5 copayment for diagnostic lab services and diagnostic procedures and tests. 
 
The records show that the visit and exam were provided for a sudden onset of aural fullness and decreased 
hearing sensitivity. For this reason, the services are considered diagnostic. Therefore, you have been asked to 
pay a $45 copayment for the specialist visit and a $5 copayment for the hearing test, for a total of $50. The 
specialist visit falls within the Hearing Services benefit category, and the hearing test falls 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 copayments for a specialist office visit and a comprehensive hearing test provided on May 20, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for infusion therapy on January 28, 2022. 
 
You asked the Plan to waive the copayment for infusion therapy. 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 $225 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges. The provider billed in the 
amount of $820 and the allowed amount is $205.58. This is less than the copayment. Therefore, results in the 
total cost sharing amount of $205.58. 
 
 
 
 You have been asked to pay a $205.58 copayment, which is less than the copayment for infusion therapy. 
Infusion therapy falls within the Outpatient Surgery and Other Medical 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 infusion therapy on January 28, 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 from 
February 24, 2022, to March 1, 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 DRG was updated.  
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 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS 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 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found that there was no laboratory or clinical evidence for sepsis. The review has 
determined that the records did not support that A41.01 - sepsis due to Methicillin susceptible staphylococcus - 
was an appropriate diagnosis code for this case. DRG 871 was not appropriate for this case.  
 
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 February 24, 2022, to March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for leg compression supplies (A4450, A4649, A6441, A6442, 
A6444, A6448, A6457, A9270,, L3260, S9999 ) provided on March 25, 2022 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the leg compression supplies. You say that the items should be covered as you 
disagree with the denial and they were medically necessary. The Plan denied your request. The Plan says the 
items denied correctly as they were received out-of-network by a provider who does not participate with 
Medicare. 
 
 
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 leg compression supplies (A4450, A4649, A6441, 
A6442, A6444, A6448, A6457, A9270,, L3260, S9999 ) provided on March 25, 2022 by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia for percutaneous image-guided destruction 
procedures by neurolytic agent on the spine or spinal cord; lumbar or sacral. 
 
You asked the Plan to pre-approve anesthesia for percutaneous image-guided destruction procedures by 
neurolytic agent on the spine or spinal cord; lumbar or sacral. You say that anesthesia for percutaneous image-
guided destruction procedures by neurolytic agent on the spine or spinal cord; lumbar or sacral is medically 
necessary. The Plan denied your request. The Plan says anesthesia for percutaneous image-guided destruction 
does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that general anesthesia is considered not reasonable and 
necessary for facet joint interventions. 
 
 
 
 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 anesthesia for percutaneous image-
guided destruction procedures by neurolytic agent on the spine or spinal cord; lumbar or sacral. Our reviewer 
says that anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or 
spinal cord; lumbar or sacral is not medically necessary. Our physician reviewer found that you do not have an 
indication for a separate anesthesia provider. There is no documentation of morbid obesity, obstructive sleep 
apnea or a medical unstable condition.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anesthesia for percutaneous image-guided destruction procedures by neurolytic 
agent on the spine or spinal cord; lumbar or sacral have not been met. Therefore, we decided that the Plan does 
not have to pre-approve anesthesia for percutaneous image-guided destruction procedures by neurolytic agent 
on the spine or spinal cord; lumbar or sacral.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Full Women's Health Panel and Sexually Transmitted 
Infection Panel provided on February 16, 2022. 
 
You asked the Plan to pay for the Full Women's Health Panel and Sexually Transmitted Infection Panel. You 
say that the Full Women's Health Panel and Sexually Transmitted Infection Panel provided on February 16, 
2022, was medically necessary. The Plan denied your request. The Plan says the Full Women's Health Panel 
and Sexually Transmitted Infection Panel provided on February 16, 2022, was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pay for the Full Women's Health Panel and Sexually Transmitted Infection Panel. Our reviewer says that the Full Women's Health Panel and Sexually Transmitted 
Infection Panel provided on February 16, 2022, was not medically necessary. Our physician reviewer found the 
enrollee presented on February 16, 2022, for an annual gynecological exam and PAP smear. The enrollee 
denied any concerns. The assessment included acute cervicitis. Testing included a Full Women's Health Panel 
for Bacterial Pathogens (CFU) and Fungal Pathogens (CFU). The documentation does not support that a Full 
Woman's Health Panel and Sexually Transmitted Infection Panel were medically reasonable and necessary for 
the enrollee 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 the Full Women's Health Panel and Sexually Transmitted Infection Panel have 
not been met. Therefore, we decided that the Plan does not have to pay for the Full Women's Health Panel and 
Sexually Transmitted Infection Panel provided on February 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan of abdomen and pelvis on March 
14, 2022.  
 
You asked the Plan to waive the copayment for a CT scan. You say that you should not be responsible for this 
copayment. The Plan denied your request. The Plan says the cost share has been applied 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 for a CT.  
 
 
 
 
 
 
 You have been asked to pay a $200 copayment for a CT scan. A CT scan falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies (PA). 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 
CT scan of abdomen and pelvis on March 14, 2022.