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

 
We decided that the Plan does not have to pay for the inpatient behavioral health services provided from June 
21, 2021, to August 2, 2021. 
 
You asked the Plan to pay for the inpatient behavioral health services provided from June 24, 2021, to August 
2, 2021. You say that the services were medically necessary. The Plan denied your request. The Plan says the 
services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient behavioral health services. Our 
reviewer says that the inpatient behavioral health services was not medically necessary. Our physician reviewer 
found the records provided do not indicate it was expected the enrollee would improve in a reasonable period 
of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or 
visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. The 
reviewer found it did not appear medically necessary and reasonable to have psychiatric care provided at the 
acute inpatient level of care rather than a lower level of care beyond the dates in question as they did not have 
any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. Therefore, the 
reviewer found that the inpatient behavioral health services were not medically reasonable or necessary. 
 
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 behavioral health services have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient behavioral health services provided from June 21, 
2021, to August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 23, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the enrollee never saw 
this provider and was an inpatient during the date of service. The Plan denied your request. The Plan says 
documentation provided shows that the enrollee received services from the provider on the date of service and 
was admitted as an inpatient the following day after the date of service. Therefore, the proper copayment was 
applied for the service that was rendered. 
 
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 $40 copayment per specialist visit.  
 
  The enrollee has been asked to pay a $40 copayment for the specialist office visit. The specialist office visit 
falls within the Physician/Practitioner services, Including doctors office visits 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 a specialist office visit provided on November 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 5, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 61322 is "Craniectomy or craniotomy, decompressive, 
with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated 
intraparenchymal hematoma; without lobectomy." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records.  
 
 Our reviewer found the operative report does not describe per CPT code description Craniectomy or 
craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without 
evacuation of associated intraparenchymal hematoma; without lobectomy.  In this case, an evacuation of 
hematoma was performed, and therefore CPT 61322 is an incorrect procedure code to report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary services provided on August 17, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
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 Domiciliary services provided on August 17, 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 a bone density study provided on October 
6, 2021. 
 
You asked the Plan to waive the copayment for the bone density study. You say that there should be no 
copayment for a routine screening. The Plan denied your request. The Plan says the proper copayment was 
applied for the service that was provided to the enrollee. 
 
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 $50 
copayment for each Medicare-covered Bone mass service. The total amount allowed was $43.34 which is less 
than the copayment amount of $50. Therefore, the copayment amount charged was $43.34. 
 
  You have been asked to pay a $43.34 copayment for the bone density study. The bone density study 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 a bone density study provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on December 13, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you would like to appeal the denied claim. 
The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and there 
was no approved 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 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 specialist office visit provided on December 13, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to a computed tomography (CT) scan provided by a network facility on 
November 9, 2021. 
 
You asked the Plan to the CT scan. You say that you are on a fixed income, and this is hurting you financially. 
The Plan denied your request. The Plan says you have been asked to pay 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 $125 
copayment for advanced imaging services at an in-network freestanding radiological facility.  
 
You have been asked to pay a $125 copayment for the CT scan. The CT scan 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 a computed tomography (CT) scan provided by a network facility on 
November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit for vision care provided on 
May 13, 2021. 
 
You asked the Plan to waive the coinsurance for the office visit for vision care. The Plan denied your request. 
The Plan says the vision exam was billed as a medical exam and the claim processed 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 Vision Care, Medicare Covered Vision Services.  
 
You have been asked to pay 20% coinsurance for the office visit for vision care. The office visit for vision care 
falls within the Vision Care, Medicare Covered Vision 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 coinsurance for an office visit for vision care provided on May 
13, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) of the chest and abdomen (74177, 
71260). 
 
You asked the Plan to pre-approve the CT scans. You say that the CT scans are medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scans. Our reviewer says that 
the CT scans are medically necessary. Our physician reviewer found the record indicates that the enrollee has 
recurrent rectal cancer with poor tolerance of chemotherapy. The record indicates that the enrollee had a CT of 
the chest in February 2022 that demonstrated indeterminate pulmonary lesions. Following operating in July 
2021, the enrollee completed a course of chemotherapy in January 2021 for residual disease. The results of the 
requested studies will guide the next therapeutic decisions. 
 
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 CT scans have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT) of the chest and abdomen (74177, 71260).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the brain 
(70551). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says 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 the MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
diabetes and unilateral exophthalmos. The record does not indicate the occurrence of acute injury. The record 
provided does not indicate the medical necessity of the requested service at this time. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the brain (70551).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Cystourethroscopy on May 28, 2021. 
 
You asked the Plan to waive the copayment for Cystourethroscopy. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says the copayment applied was 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 $335 
copayment for Cystourethroscopy.  
 
You have been asked to pay a $335 copayment for Cystourethroscopy. Cystourethroscopy 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 Cystourethroscopy on May 28, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on December 9, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the service was medically necessary. 
 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for genetic testing provided on December 9, 2021, by an out-of-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from May 20, 2020, to May 
23, 2020, as billed with Diagnosis Related Group (DRG) 572. 
 
 You asked the Plan to pay for inpatient care billed with DRG 572. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 572 is not 
supported as the principal procedure of excision of left upper leg subcutaneous/fascia, open approach, is not 
supported in the medical record. There is no supporting operative report to validate the depth of the procedures 
performed during this inpatient admission. The Plan argues that DRG 594 is more appropriate in this case. 
 
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. 
 
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 inpatient care billed with DRG 572. Our 
reviewer says that the documentation does not support the billing of principal procedure excision of left upper 
leg subcutaneous/fascia, open approach. Our physician reviewer found that the documentation indicates that the 
enrollee presented to the emergency department for the evaluation and treatment of left hip ulcer. Discharge 
summary stated that the enrollee was admitted for large left hip pressure ulcer and possible debridement. 
General surgery was consulted. The enrollee underwent debridement of left hip decubitus ulcer. Operative note 
stated that excisional debridement of the lesion was done using scalpel and cautery. The dimensions of the 
stage 3 decubitus ulcers were 8cm  7cm  2cm. Hemostasis was achieved, and the wound was irrigated with 
saline and dressing was applied. As per the operative report, excisional debridement was performed up to the 
skin level only. There was no supporting documentation in operative report to validate for subcutaneous or 
fascia level. The review has determined that the medical records did not support the billing of principal 
procedure of excision of left upper leg subcutaneous/fascia, open approach. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 572 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from May 20, 2020, to May 23, 2020, as 
billed with Diagnosis Related Group (DRG) 572.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on December 17, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and service was rendered in good faith. The Plan denied your request. The Plan says the 
rendering provider is an out-of-network provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 home health visit provided on December 17, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on November 9, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the provider called you to come 
into the office and said it would be an annual visit. The Plan denied your request. The Plan says documentation 
provided support an evaluation and management of services rendered by the provider. Therefore, the proper 
copayment was applied. 
 
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 medical care or surgery services in a Primary Care Physician's office.  
 
  You have been asked to pay a $5 copayment for the office visit. The office visit falls within the 
Physician/Practitioner services, including doctors office visits 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 office visit provided on November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider. 
 
You asked the Plan to pre-approve the office visit. You say that you have seen this doctor in the past. The Plan 
denied your request. The Plan says they have provided you a list of in-network neurosurgeons. 
 
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 
an office visit to be provided by an OON provider.