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

 
We decided that the Plan does not have to pre-approve an inpatient admission for a left total knee arthroplasty. 
 
You asked the Plan to pre-approve the inpatient admission. You say that the enrollee has severe knee pain. The 
Plan denied your request. The Plan says this request does not meet the coverage criteria. 
 
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 pre-approve the inpatient admission. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found this case meets Ambulatory Operative Status Criteria of the guidelines because there 
are no active or unstable comorbidities that significantly increase risk or require prolong postoperative 
monitoring. Our reviewer also found that the review has determined that the records do not support the need for 
an inpatient stay for the approved total knee arthroplasty. 
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient admission for a left total knee arthroplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 12, 2021. 
 
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 was not billed correctly. 
 
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 these services have not been met. Specifically, this claim was billed with the office POS code. The 
records do not support that the sample was taken in an office setting. Therefore, we decided that the Plan does 
not have to pay for the laboratory services rendered on October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 19, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you were not aware of the requirement of 
obtaining a prior authorization, specifically for this member's plan type at the time of rendering services. You 
also say that you conducted in good faith, the laboratory testing ordered by the referring provider, who deemed 
the services to be medically necessary. The Plan denied your request. The Plan says the rendering provider is a 
non-participating provider with the Plan and the referring provider involved in these services is a non-
participating provider with the Plan. The Plan also says that they did not authorize any services for this 
provider or the referring provider. 
 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 laboratory services provided on October 19, 2021, 
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0428) provided on September 29, 
2021. 
 
You asked the Plan to pay for the ambulance services. You say that these services were necessary and were 
billed according to Medicare guidelines. The Plan denied your request. The Plan says this claim was billed with 
an incorrect revenue code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this 
case, the services were billed with revenue code 0542. Medicare requires that ambulance services provided on 
or after January 1, 2001, must be reported with revenue code 0540. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance services (A0428) provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 11, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is no evidence of an established relationship 
between the enrollee and ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the office visit (99202) provided on 
February 11, 2021. have been met. Specifically, the documentation submitted does not include sufficient 
clinical information. Additionally, there is no evidence of an established relationship between the enrollee and 
ordering physician.. Therefore, we decided that the Plan does not have to pay for the office visit (99202) 
provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a spinal canal injection and does not have 
to waive the coinsurance for a Medicare Part B drug provided on September 1, 2021. 
 
You asked the Plan to waive the copayment for a spinal canal injection and to waive the coinsurance for a 
Medicare Part B drug. You say that you disagree with the charges. The Plan denied your request. The Plan says 
the claims were processed correctly, and you are being charged the correct 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 $250 copayment for outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers. Your contract with the Plan 
also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. 
 
You received a spinal canal injection at an outpatient hospital facility on September 1, 2021. A spinal canal 
injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay $75, which is 
less than the $250 copayment.  
 
You received a Medicare Part B drug on September 1, 2021. The total allowed amount is $5.55 and 20% of that 
is $1.11.  
 
The total amount you owe is: $76.11.  
 
You have been asked to pay the total amount of $76.11 for a spinal canal injection and a Medicare Part B drug. 
A spinal canal injection falls within the outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers benefit category. A Medicare Part B drug 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 waive the copayment for a spinal 
canal injection and does not have to waive the coinsurance for a Medicare Part B drug provided on September 
1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Prodigy Glucometer, Prodigy test strips, Prodigy control 
solution and Sterilance Twist top lancets with the Sterilance lancing device, provided on April 1, 2021. 
 
You asked the Plan to pay for the diabetic testing supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says these are non-preferred items. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical 
Equipment (DME) to only those preferred brands and manufacturers 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the diabetic testing supplies have not been met. Specifically, there is no indication these items are 
medically necessary over the Plan's preferred brands. Therefore, we decided that the Plan does not have to pay 
for a Prodigy Glucometer, Prodigy test strips, Prodigy control solution and Sterilance Twist top lancets with the 
Sterilance lancing device, provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 22, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship between the 
enrollee and ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for the office visit (99202) provided on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON second opinion. You say that the network provider is taking too 
long to have someone see you. You say that your cancer is very serious and the network provider you were 
seeing was dragging their feet. You say that this is putting your life at risk. The Plan denied your request. The 
Plan says you can obtain a second opinion with a doctor within their network. The Plan says that they have 
providers within their network who can treat your condition and who are different from the one you have seen 
and been dissatisfied with. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a second opinion to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 14, 2020, 
through November 12, 2020. 
 
You asked the Plan to pay for home health services. You say that per the representative, all data needed is there 
and the claim would be sent back to be reprocessed. You say that the documentation should be thoroughly 
reviewed, and the decision should be reconsidered. The Plan denied your request. The Plan says the claim is 
required to have a both the first visit and service location reported with the same date of service. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the location 
where services were provided must always be reported along with the first visit reported on the claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from October 14, 
2020, through November 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 17, 2021. 
 
You asked the Plan to pay for the services provided. You say that the specimens are sent to the facility by the 
enrollee's primary physician. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. The claim lists a place of service as an independent laboratory. We looked at the file and the rules. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not show that the enrollees sample was obtained at the independent laboratory. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing services provided on March 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 88321 x3) provided on 
March 31, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. Per above review CPT 
88321 x3 was not billed in accordance with Medicare National Correct Coding Initiative Policy -Medically 
Unlikely Edits (MUE). This is not a medical necessity denial. CPT 88321 has an MUE value of "1", Provider 
billed "4" units. Hence claim denied correctly. The Plan states to please be advised that the denial for procedure 
code 88321 x1 unit paid under another case number by the health plan. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (CPT code 88321 x3) provided on March 31, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the denial of authorization for SNF care is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for an echocardiogram (code 93306) provided on August 
27, 2021. 
 
You asked the Plan to reduce the copayment for an echocardiogram. You say that you only had an 
echocardiogram and did not have any surgery on this day. You also say that you were told your copayment 
would be $30, but then received a bill for $549.54. The Plan denied your request. The Plan says that 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. Your 
contract with the Plan says that enrollees must pay a $50 copayment for outpatient diagnostic testing, including 
echocardiograms.  
 
The records show you did not have outpatient surgery. The Plan says you must pay $549.54 for an 
echocardiogram. Based on the Plan contract, however, you cannot be asked to pay more than a $50 copayment 
for an echocardiogram. Therefore, we decided that the Plan has to reduce the copayment for an echocardiogram 
(code 93306) provided on August 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a surgical injection (code 20551) provided 
on October 5, 2021. 
 
You asked the Plan to waive the copayment for a surgical injection. You say that the copayment should be 
waived. The Plan denied your request. The Plan says the copayment amount 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 $295 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.  
 
You have been asked to pay $233.98 for a surgical injection, which is less than the $295 copayment. A surgical 
injection falls within the Outpatient Surgery an 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 a surgical injection (code 20551) provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ophthalmology fundus photograph 
provided on November 30, 2021. 
 
You asked the Plan to waive the copayment for an ophthalmology fundus photograph. You say that you were 
unaware that you were having eye photos taken and that there was an additional charge for 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 $35 
copayment for an outpatient diagnostic test.  
 
You have been asked to pay a $35 copayment for an ophthalmology fundus photograph. An ophthalmology 
fundus photograph 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 copayment for an ophthalmology fundus photograph provided 
on November 30, 2021.  
 
Your complaint about not being told you were having pictures taken and the associated extra cost is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON pain management services. You say that you want a wig. You say 
that the worker's compensation provider will not address your metastatic ovarian cancer pain. You say that you 
have been asked to go on a three-month holiday from your pain medication, which you cannot do. The Plan 
denied your request. The Plan says there are providers within their network who can provide pain management 
services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
pain management services to be provided by an out-of-network (OON) provider.