Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist visit provided on September 30, 2021. 
 
You asked the Plan to pay for a specialist visit. You say that this was medically necessary and should be 
covered. 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 a specialist visit 
provided on September 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from August 16, 
2022, to August 20, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you cannot afford this 
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 $290 
copayment per day for days 1 to 5 for inpatient hospital care. You were hospitalized for 4 days, resulting in a 
$1,160 total copayment ($290 x 4 = $1,160).  
 
You have been asked to pay a $1,160 copayment per day for an inpatient stay. This item/service 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 waive the copayment for an inpatient 
stay provided from August 16, 2022, to August 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have waive the cost share amount for the acute inpatient hospital care 
provided from September 4, 2021, to September 6, 2021. 
 
You asked the Plan waive the cost share amount for the inpatient care. You say that you cannot afford to pay 
this bill. 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 $350 
copayment per day for days 1 to 5 for Inpatient Hospital Care.  
 
You have been asked to pay a $350 copayment per day for days 1 to 5 for the inpatient care for 2 days, or $700. 
This service 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 waive the cost 
share amount for the acute inpatient hospital care provided from September 4, 2021, to September 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transitional care visit provided on March 
21, 2022. 
 
You asked the Plan to waive the copayment for a transitional care visit. You say that this provider is a primary 
care provider, you should not have this copay. 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 outpatient hospital services. 
 
You have been asked to pay a $35 copayment for a transitional care visit. This item/service falls within the 
outpatient hospital services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
transitional care visit provided on March 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an automatic blood pressure monitor provided on June 24, 
2022. 
 
You asked the Plan to pay for an automatic blood pressure monitor. You say that you would like to be 
reimbursed for this equipment. The Plan denied your request. The Plan says these services are not covered by 
Medicare or the Plan.  
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pay for an automatic blood pressure monitor provided on 
June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care on May 25, 2022. 
 
You asked the Plan to waive the copayment for urgent care. You say that you want to appeal the amount being 
charged. 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 $30 
copayment for each Medicare-covered urgent care facility visit. This copayment is not waived if you are 
admitted as an inpatient to the hospital within 24 hours for the same condition. Urgently needed services are 
provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate 
medical care. Urgently needed services may be furnished by network providers or by out-of-network providers 
when network providers are temporarily unavailable or inaccessible. 
 
 
 
 You have been asked to pay a $30 copayment for urgent care. This item/service falls within the Urgently 
needed services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for urgent care on May 25, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for emergency care provided on June 3, 2022, 
and an MRI provided on June 7, 2022.  
 
You asked the Plan to waive the copayments for emergency care and an MRI. You say that you should not be 
responsible to pay this because the test could not be performed for the fine vessels in your head. 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 $90 
copayment for each emergency care visit. Your contract with the Plan also clearly says that you must pay a 
$225 copayment for each advanced imaging service, including an MRI.  
 
 You have been asked to pay a $90 copayment for emergency care provided on June 3, 2022. This item/service 
falls within the emergency care benefit category. You have also been asked to pay $184.10 for an MRI 
provided on June 7, 2022. This amount is less than the standard cost sharing amount. This item/service falls 
within the outpatient hospital services benefit category. The total amount you owe is $274.10 ($90 copayment 
+ $184.10 copayment + $274.10). 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 emergency care 
provided on June 3, 2022, and an MRI provided on June 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on 
May 2, 2022, to May 26, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery services. You say that you disagree with the 
copayment amount. 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 $360 
copayment per visit for outpatient Surgery/Medicare-covered surgery.  
 
You have been asked to pay a $360 copayment per visit for outpatient surgery services. The total amount you 
are being asked to pay is $720 ($360 x 2 visits = $720). This item/service falls within the outpatient 
Surgery/Medicare-covered surgery 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 
outpatient surgery services provided on May 2, 2022, to May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine eye refraction (92015) provided on August 23, 
2022. 
 
You asked the Plan to pay for the routine eye refraction. You say that you would like this service covered. Plan 
denied your request. The Plan says you have exceeded the frequency limit for this service. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once per calendar year. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that a routine eye 
refraction was previously covered on February 4, 2022. Based on this information, we decided that the Plan's 
frequency limit for coverage of the routine eye refraction has been exceeded. Therefore, we decided that the 
Plan does not have to pay for the routine eye refraction (92015) provided on August 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on June 22, 2022. 
 
You asked the Plan to pay for procedure code 99223. 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. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the file shows that the 
enrollee was admitted as an outpatient on the date of service at issue in this appeal. Code 99223 is an inpatient code. Based on this information, we decided that Medicare rules for coverage of procedure code 99223 have 
not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99223) 
provided on June 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 12 physical therapy visits. 
 
You asked the Plan to pre-approve  the physical therapy. You say that since you have been continuing to do the 
physical therapy without professional supervision and guidance you have developed a sharp pain in your right 
knee. The Plan denied your request. The Plan says an additional 12 physical therapy visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you have previously been treated with outpatient therapies and 
should be independent with a home exercise program. You have had no recent injury or a decline in function. 
The additional therapy services are not appropriate duration and frequency for treatment of your medical 
condition and therefore are not medically 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an additional 12 physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel testing (87486, 87502, 87581, 
87640, and 87632) provided on July 27, 2022. 
 
You asked the Plan to pay for the respiratory pathogen panel testing. 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. 
Providers must report services with the appropriate CPT code. A respiratory pathogen panel test must not be 
unbundled and billed as individual components regardless of the fact that the panel reports multiple individual 
pathogens and/or targets. 
 
We looked at the file and Medicare rules. We find that respiratory testing must not be unbundled. Procedure 
codes 87486, 87502, 87581, 87640, and 87632 have been billed as individual components rather than as part of 
the panel. Based on this information, we decided that Medicare rules for coverage of the respiratory panel have 
not been met. Therefore, we decided that the Plan does not have to pay for the respiratory pathogen panel 
testing (87486, 87502, 87581, 87640, and 87632) provided on July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on August 30, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you went to see your primary 
care provider but saw an NP. 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 $45 
copayment for urgently needed services. 
 
You have been asked to pay a $45 copayment for an urgent care visit. This item/service falls within the 
urgently needed services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an urgent 
care visit provided on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a specialist visit. You say that you would like to continue care with your 
current provider who is now out-of-network. The Plan denied your request. The Plan says the requested 
provider is no longer contracted with your Plan and services requested are available with an in-network 
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 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 specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 6, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee on November 22, 
2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the claim should be reconsidered for 
payment. The Plan denied your request. The Plan says that based on the information received, it does not 
support an inpatient stay. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that based on the very slow and ineffective progress initially observed in the emergency 
department (ED) and observation level of care, it was expected that the patient would need a longer period of 
time to allow for additional treatment. It was expected that the patient's necessary hospital care including ED 
and observation care would span two midnights based on the provided records.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee on November 22, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like reconsideration because the services 
are medically necessary. The Plan denied your request. The Plan says a SNF admission is not medically 
necessary. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a 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 SNF care.