Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the colonoscopy with lesion 
removal/biopsy and the esophagogastroduodenoscopy provided on June 16, 2022. 
 
You asked the Plan to waive the coinsurance for the colonoscopy and the esophagogastroduodenoscopy. You 
say that you do not know this was an out-of-network service. 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 40% 
coinsurance per visit, for out-of-network Medicare-covered outpatient surgery or procedure provided in a 
hospital facility.  
 You have been asked to pay 40% coinsurance for the colonoscopy and the esophagogastroduodenoscopy. You 
have been asked to pay a total of $778.58. These items/services fall within the outpatient surgery, including 
services provided at hospital outpatient facilities 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 the colonoscopy with lesion removal/biopsy and the esophagogastroduodenoscopy provided on 
June 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the drug injection and drug administration 
provided on August 17, 2022. 
 
You asked the Plan to waive the cost share for the drug injection and drug administration. You say that you 
cannot afford to get this service regularly. 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 20% coinsurance for in-network Medicare Part B drugs. Your contract with the Plan also clearly says that you must 
pay a $250 copayment for in-network surgical or other services provided at an outpatient hospital.  
 
You have been asked to pay $166.20, which is 20% coinsurance of the allowed amount for the drug injection 
($831.00 allowed amount x 20% coinsurance = $166.20). This item/service falls within the Medicare Part B 
drugs benefit category.  
 
You have also been asked to pay $194.50, which is less than the standard $250 copayment for the drug 
administration. This item/service falls within the outpatient surgery benefit category. You have been asked to 
pay a total of $360.70 ($166.20 coinsurance + $194.50 copayment = $360.70). 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 cost share for the drug injection and drug administration provided on August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the medical eye exam and ophthalmic 
ultrasound provided from October 4, 2022, and October 20, 2022. 
 
You asked the Plan to waive the copayments for the eye exam and ultrasound. You say that you were told this 
was a diabetic eye exam with no 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 $35 
copayment for each Medicare-covered eye exam. Your contract with the Plan also clearly says that you must pay a $20 copayment for each basic imaging service, including ultrasounds. 
 
You have been asked to pay a $35 copayment for the eye exam and ultrasound. This item/service falls within 
the vision care benefit category. You have also been asked to pay a $20 copayment for the ophthalmic 
ultrasound. This item/service falls within the outpatient diagnostic tests and therapeutic services benefit 
category. You have been asked to pay a total of $55 ($35 copayment + $20 copayment = $55). 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 the medical eye exam and ophthalmic ultrasound provided from 
October 4, 2022, and October 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
14, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service December 14, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on November 2, 2022. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision. 
  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of radiology services provided have not been met. The procedure is a barium swallow study, and this 
means that it involves the administration of a substance to the enrollee. Therefore, we decided that the Plan 
does not have to pay for radiological services provided on November 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 12, 2022 to 
February 4, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 12, 2022 to 
February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dermatology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve dermatology services. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receive from an out-of-
network provider (a provider who is not part of the plan's network) will not be covered. This means that the 
enrollee will have to pay the provider in full for the services furnished. 
 
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 
dermatology services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transitional care management (TCM) services provided 
on September 27, 2022. 
 
You asked the Plan to pay for the TCM services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the enrollee was discharged on September 10, 2022. 
Medicare says only 1 TCM service is covered per patient during the TCM period. The file shows the same 
provider billed and was paid for date of service, September 13, 2022, for procedure code 99496. Therefore, we 
decided that the Plan does not have to pay for the transitional care management (TCM) services provided on 
September 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on November 01, 2022, billed 
with procedure codes 99204, 74230, 72040, 70100, 70310, and 74240. 
 
You asked the Plan to pay for the medical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the wrong place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for mobile units serving an entity with its own 
POS code, the entity's POS code should be reported. 
 We looked at the file and Medicare rules. Place of service 11 was billed, however the documentation does not 
support that the services were done in an office setting. Based on this information, we decided that Medicare 
rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have 
to pay for medical services provided on November 01, 2022, billed with procedure codes 99204, 74230, 72040, 
70100, 70310, and 74240.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 29, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services are supported in the records. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on December 29, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a comprehensive oral evaluation (D0150) and a panoramic radiographic 
image (D0330) provided on November 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had a referral that was approved by the Plan 
and the services were medically necessary. The Plan denied your request. The Plan says that your benefit for 
the requested items or services has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested items or services was 
previously exhausted. Therefore, we decided that the Plan has to pay for a comprehensive oral evaluation 
(D0150) and a panoramic radiographic image (D0330) provided on November 8, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on November 14, 2022. 
 
You asked the Plan to pay for rest home visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for rest home visit provided 
on November 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service November 
23, 2022. 
 You asked the Plan to pay for procedure code 72170. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 72170 is bundled into 
payment for code 73501. 
 
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 72170 
is a column II code to column I code 73501. 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 72170 billed for date of service November 23, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the inpatient hospital stay provided from 
December 11, 2022, to December 16, 2022. 
 
You asked the Plan to waive the deductible for the inpatient hospital stay. You say that the Plan should cover 
this fully. 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. Your 
contract with the Plan says that there is a $300 deductible which applies to inpatient hospital care.  
 
The item or service you asked the Plan to waive the deductible for falls within the inpatient hospital care 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 
deductible which applies to inpatient hospital care. This cost sharing is a contractual obligation that had not 
been met at the time the inpatient hospital stay was received from December 11, 2022, to December 16, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for the inpatient hospital stay 
provided from December 11, 2022, to December 16, 2022.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the required care can be provided in an alternate setting. 
 
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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
August 6, 2021, to August 12, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the inpatient hospital 
stay should be considered in-network. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $395 copayment per day, for days 1 to 5 and a $0 copayment for additional days of inpatient 
hospital care.  
 
The record shows that you were charged the in-network benefit level. The enrollee has been asked to pay a 
$395 copayment per day, for days 1 to 5 for the inpatient hospital stay. You have been asked to pay a total of 
$1,975 ($395 copayment x 5 days = $1,975). You have not been charged for any additional days. This 
item/service falls within the inpatient hospital care benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for the inpatient hospital stay provided from August 6, 2021, to August 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are better suited for 
your needs than the services that you would receive in a skilled nursing facility. The Plan denied your request. 
The Plan says when you are ready to leave the hospital, you can safely receive your care in another setting, 
such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. All medically necessary care is being provided in the current 
acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 27, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that you believe it was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
on December 27, 2022.