Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for a psychotherapy session provided on November 3, 2021. 
 
You asked the Plan to pay for the psychotherapy session. The Plan denied your request. The Plan says that the 
provider must attempt to consult the attending or primary care physician about the services furnished and 
document the consent or declination date to consultations, and the date of consultations in the patients medical 
record. There was no documentation of contact in the patient record. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. The only exception 
to the consultation requirement is in cases where the patient's primary care or attending physician refers the 
patient to the CP or LCSW. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy session have been met. Specifically, the record shows that the enrollee was 
referred to this provider by their attending/primary physician. Therefore, we decided that the Plan has to pay 
for a psychotherapy session provided on November 3, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device rendered on September 1, 
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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that claims for E0675 will be denied as not reasonable and 
necessary.  
 
We looked at the file and Medicare rules. The file shows that the services were billed with procedure code 
E0675. These services are denied by Medicare as not medically necessary. Therefore, we decided that the Plan 
does not have to pay for the pneumatic compression device rendered on September 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on October 7, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you fell and were not able to get up without 
assistance. The Plan denied your request. The Plan says since there was no transport provided, there is no 
payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 7, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on October 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment you purchased from an out-of-
network (OON) provider on June 25, 2021. 
 
You asked the Plan to pay for the oxygen equipment. You say that it was more cost effective for you to 
purchase this item than to pay for monthly copayments. You said that it was not your understanding that prior 
approval was required. The Plan denied your request. The Plan says items purchased from an out-of-network 
provider are 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 in this case is not a network provider with the Plan. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the 
Plan does not have to pay for the oxygen equipment you purchased on June 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an inpatient hospital stay provided from 
March 19, 2019, to March 25, 2019. 
 
You asked the Plan to reduce the copayment for an inpatient hospital stay. You say that you never received a 
bill from the hospital and already paid the hospital bills after having surgery. You also say that you were told 
by the hospital that the records showed no patient responsibility. 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 $250 
copayment for days 1-6 of an in-network inpatient hospital stay. There is no charge for day 7 and after. 
 You have been asked to pay a total of $1,500, which is a $250 copayment for days 1-6 of an inpatient hospital 
stay ($250 copayment x 6 days = $1,500). There is no charge for day 7 and after. An 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 reduce the copayment 
for an inpatient hospital stay provided from March 19, 2019, to March 25, 2019.  
 
Your complaint about the billing confusion and the collection notices you received are 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
uremia and end stage renal disease and began hemodialysis. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 10, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you were not aware prior authorization was needed. 
The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 
prior authorization. 
 
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 referring provider 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 the laboratory services provided on June 10, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a shoulder arthrocentesis (code 20610) 
provided on November 23, 2021. 
 
You asked the Plan to waive the copayment for a shoulder arthrocentesis. You say that you only had a 
cortisone injection and did not have surgery. 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 $250 
copayment for outpatient surgery at an outpatient hospital.  
 
The record shows that a shoulder arthrocentesis (code 20610) is considered a surgical procedure. You have 
been asked to pay a $250 copayment for a shoulder arthrocentesis. A shoulder arthrocentesis 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 shoulder arthrocentesis 
(code 20610) provided on November 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pantoprazole tablets. 
 
You asked the Plan to pre-approve Pantoprazole tablets. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says Pantoprazole tablets are not covered under the 
enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pantoprazole tablets.  
 
 Benefits for Pantoprazole tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care rendered on September 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 services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that POS code 21 must be billed for inpatient hospital 
services. 
 
 
 We looked at the file and Medicare rules. The file shows that the services were not billed with required POS 
code 21. Therefore, we decided that the Plan does not have to pay for the initial hospital care rendered on 
September 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 6, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services were necessary. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 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 September 6, 
2021, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation services 
provided on November 26, 2021, and December 10, 2021. 
 
You asked the Plan to waive the copayments for ambulance transportation. You say that you were not told that 
original Medicare would not cover what the insurance company does not. You also say that you cannot afford 
these copayments. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $325 copayment per trip for ambulance transportation.  
 
 The enrollee has been asked to pay a total of $650, which is a $325 copayment for ambulance transportation on 
November 26, 2021, and December 10, 2021 ($325 + $325 = $650). Ambulance transportation falls within the 
Ambulance Services 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 copayments for 
ambulance transportation services provided on November 26, 2021, and December 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 21, 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 services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
 
 We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on October 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy visits provided on 
November 1, 2021, and November 9, 2021. 
 
You asked the Plan to waive the copayments for physical therapy visits. You say that you were never informed 
of any out of pocket charges, otherwise you would have cancelled the therapy. You also say that your therapy 
referral was approved and then denied during therapy. 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 $5 
copayment for physical therapy visits at a comprehensive outpatient rehab facility.  You have been asked to pay a total of $10, which is a $5 copayment for physical therapy visits on November 1, 
2021, and November 9, 2021 ($5 copayment + $5 copayment = $10). Physical therapy visits 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 copayments for 
physical therapy visits provided on November 1, 2021, and November 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an upper gastrointestinal (UGI) endoscopy 
with biopsy provided on October 19, 2021. 
 
You asked the Plan to waive the copayment for an UGI endoscopy. You say that the doctor performing the 
procedure advised you there would be no cost other than a $45 fee. You say that you would not have had the 
procedure if the cost was explained prior. 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 $350 
copayment for outpatient surgical procedures, including a diagnostic endoscopy at an ambulatory surgical 
center.  You have been asked to pay a $350 copayment for an UGI endoscopy. An UGI endoscopy 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 an upper gastrointestinal 
(UGI) endoscopy with biopsy provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for intravenous (IV) infusions provided from 
July 29, 2021, to August 7, 2021. 
 
You asked the Plan to waive the copayments for IV infusions. You say that your doctor ordered/prescribed 10 
days of IV antibiotics. You also asked if the claim could be filed differently. 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 $335 
copayment for in-network outpatient medical services at an outpatient hospital.  
 
 The record shows that intravenous infusions are considered a medical service/procedure. You have been asked 
to pay the allowed amount of $186.82, which is less than the $335 copayment for 10 days of IV infusions. You 
have been asked to pay a total of $1,868.20 ($186.82 x 10 days = $1,868.20). IV infusion 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 copayments for intravenous (IV) 
infusions provided from July 29, 2021, to August 7, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the brain. 
 
You asked the Plan to pre-approve an MRI of the brain. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the brain. Our reviewer says 
that the services are medically necessary. Our physician reviewer found all factors considered you qualify for 
an MRI of the brain based upon your psychosocial history and documented short term memory loss in the face 
of normal labs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the brain have been met. Therefore, we decided that the Plan has to 
pre-approve a magnetic resonance imaging (MRI) of the brain.  
 
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 the ConfirmMDx testing rendered on July 6, 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 testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that ConfirmMDx testing is covered for males with 
previous negative prostate biopsy who are being considered for repeat biopsy. 
 
We looked at the file and Medicare rules. The file does not contain documentation of a previous prostate 
biopsy. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing rendered on July 6, 
2021.