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

 
We decided that the Plan does not have to reduce the copayment for skin debridement (code 97597) provided 
on January 13, 2022, and January 27, 2022.  
 
You asked the Plan to reduce the copayment for skin debridement. You say that the office staff and doctor told 
you this was not a surgery. You also say the claims should be rebilled with the $35 office visit copayment. 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 each outpatient surgery at an outpatient hospital.  
 
 According to Medicare, skin debridement code 97597 is considered a surgical procedure. You have been asked 
to pay the allowed amount of $187.64, which is less than the $350 copayment for each skin debridement on 
January 13, 2022, and January 27, 2022. You have been asked to pay a total of 375.28 ($187.64 copayment + 
$187.64 copayment = $375.28). Skin debridement 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 reduce the copayment for skin debridement (code 97597) provided on January 13, 2022, and 
January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on July 14, 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 the service was rendered in good faith. The Plan denied your request. The Plan says the 
rendering provider is an OON 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 July 14, 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 a specialist office visit provided on 
September 3, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that this visit was a follow up 
to a previous visit where medication was prescribed that affected your health. 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 $40 
copayment for a specialist office visit.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$40 copayment for a specialist office visit. A specialist 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 a specialist office visit provided on September 3, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an emergency room (ER) visit provided on October 2, 
2021. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you did not receive any services and 
never spoke to a nurse or doctor to explain why you were there. The Plan denied your request. The Plan says 
that you have been charged the correct cost sharing amount. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical record to confirm if services took place. 
Without the medical records we are unable to determine if the cost share applied is correct. Therefore, we 
decided that the Plan has to waive the copayment for an emergency room (ER) visit provided on October 2, 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 
4, 2021, to May 10, 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 DRG 011 was inappropriately billed. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of inpatient hospital services provided to 
the enrollee from May 4, 2021, to May 10, 2021. have been met. Despite multiple requests, the provider did not 
supply adequate medical records support the use of DRG 011 in this case.. Therefore, we decided that the Plan 
does not have to pay for inpatient hospital services provided to the enrollee from May 4, 2021, to May 10, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that the provider you would like to be 
transported to is the only neurologist in the area who treats your condition. The Plan denied your request. The 
Plan says the request is for an additional 25 miles for a total of 75 miles, which exceeds the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles.  
 We looked at your request, the records in the case file, and the rules. The record shows that you are requesting 
to be transported further than 50 miles per trip. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional transportation mileage (A0170).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue. 
 
You asked the Plan to pre-approve transurethral destruction of prostate tissue. You say that transurethral 
destruction of prostate tissue is medically necessary. The Plan denied your request. The Plan says according to 
the Plan's Medical Policy, this procedure has not been shown to be a safe and helpful treatment for this 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 transurethral destruction of prostate 
tissue. Our reviewer says that the requested transurethral destruction of prostate tissue is not considered 
medically reasonable and necessary in this case. Our physician reviewer found that i this case, the record 
indicates that you have benign prostatic hypertrophy. The record is insufficient to determine the medical 
necessity of the requested procedure. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral destruction of prostate tissue have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
brain provided on February 10, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that you should not be charged a second time 
since the same procedure on January 27, 2022, was not fully completed. 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 $200 
copayment per provider, and per date of service for complex radiology services, including MRIs.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$200 copayment for an MRI on February 10, 2022. An MRI 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 
magnetic resonance imaging (MRI) of the brain provided on February 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the head or brain and a CT scan of the 
neck soft tissue. 
 
You asked the Plan to pre-approve a CT scan of the head or brain and a CT scan of the neck soft tissue. You 
say that the CT scans are medically necessary. The Plan denied your request. The Plan says the Plan does not 
have documentation of a physical exam results that included a detailed nervous system exam that supports 
imaging. 
 
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 a CT scan of the head or brain and a CT 
scan of the neck soft tissue. Our reviewer says that a CT scan of the head or brain and a CT scan of the neck 
soft tissue is not medically necessary. Our physician reviewer found that the enrollee had a thyroid ultrasound 
on November 10, 2021, which revealed no thyroid nodule but did show a 1.2 centimeter left cervical lymph 
node. No follow-up neck sonogram has been obtained. The recent physical exam did not mention a neck mass 
to be palpable. The medical necessity of a CT has not been established in the records provided.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the head or brain and a CT scan of the neck soft tissue have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the head or brain and 
a CT scan of the neck soft tissue.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kidney transplant evaluation to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve kidney transplant evaluation. You say that you would like to appeal the 
denial of the claim. The Plan denied your request. The Plan says the member's plan excludes coverage for this 
OON service and has already been approved for this evaluation at a separate 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 
kidney transplant evaluation to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for cataract surgery provided on January 6, 
2022. 
 
You asked the Plan to reduce the copayment for cataract surgery. You say that you were told your copayment 
would only be $200. You also say you are on a fixed income. 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 surgery at an outpatient hospital facility.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$350 copayment for cataract surgery. Cataract surgery 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 reduce the copayment for cataract surgery provided on January 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from September 21, 
2021, through September 25, 2021, billed with procedure code 0JH70MZ. 
 
You asked the Plan to pay for the inpatient care as billed. You say that this should be paid because the service 
was approved. The Plan denied your request. The Plan says this was billed using a noncovered procedure code. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient claims are processed by the MCE to 
check for noncovered procedures among other items. 
 
We looked at the file and Medicare rules. This claim was billed with a procedure code that is specifically noncovered per the MCE. Based on this information, we decided that Medicare rules for coverage of the 
inpatient care as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
inpatient hospital care provided from September 21, 2021, through September 25, 2021, billed with procedure 
code 0JH70MZ.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visits provided on January 10, 
2022 and January 27, 2022 
 
You asked the Plan to waive the copayment for telehealth visits. You say that you would like to appeal the 
copayment for the appointments. You say both these visits would have no copayment if not for multiple delays 
from the doctor. The Plan denied your request. The Plan says you have been charged the correct copayment 
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 $30 
copayment for certain telehealth services with a specialty physician. Additional telehealth services certain 
telehealth services, including primary care, specialty physician, outpatient mental health, outpatient substance 
abuse, urgent care, physical therapy, occupational therapy, speech therapy, kidney disease education, and 
diabetic self-management training. 
 
You have been asked to pay a total of $60 ($30 x 2 visits = $60). The telehealth visits fall within the 
Physician/Practitioner services, including doctor's 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 telehealth visits provided on January 10, 2022 and January 27, 2022
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repeat bariatric surgery and inpatient hospital admission. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee's records do not show that they have had repeat studies of their stomach to 
see if the ulcer is still present after medical treatment. 
 The Plan must follow Medicare rules. The rules say that services are covered when they are medically 
necessary. 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 the services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee has a marginal ulcer a known potential complication of gastric bypass surgery. In 
general risk factors include smoking, alcohol use, steroids, non-steroidal anti-inflammatory drugs (NSAIDs) 
and sometimes h pylori. It can also result from dietary intolerance and ongoing mechanical inflammation from 
vomiting. It is unclear whether this patient has been screened for rheumatoid factors, whether there has been a 
dietary evaluation to look at eating behaviors (possibly contributing) and how long she has been on maximal 
medical management. In addition, a period of downstaging textured foods to only full liquids and or 
consideration of a trial of total parenteral nutrition can be considered before proceeding with a surgical revision 
which may or may not always improve or treat marginal ulcer, particularly if tissue ischemia is contributing 
factor and or ongoing rheumatoid factor and or vomiting history are not adequately evaluated. 
 
We looked at this physician's review, the file, and Medicare rules. As our doctor found that the surgery itself is 
not reasonable or necessary, the inpatient stay for said unnecessary surgery is also not reasonable in this case. 
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 repeat bariatric surgery and inpatient hospital 
admission.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on January 
19, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you are a senior citizen, and 
you are on a fixed income. You say that this copayment is too expensive. The Plan denied your request. The 
Plan says you have been charged the correct copayment 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 per one-way trip for Medicare-covered ambulance services.  
 
 
 You have been asked to pay a $350 copayment for ambulance transport. The ambulance transport falls within 
the Ambulance 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 ambulance 
transport provided on January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 11, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you were unaware the reason a previous claim was 
paid for due to a COVID diagnosis and that you assumed the service provided by the same provider would be 
paid for as well. The Plan denied your request. The Plan says the provider is out-of-network and authorization 
is required prior to 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 an office visit provided on January 11, 2022 by an 
out-of-network (OON) provider.