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

 
We decided that the Plan does not have to pay for lab services provided on November 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 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 November 18, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the unlisted molecular pathology services, Guardant360 (81479) 
provided January 18, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of this 
claim and provide full reimbursement against the enrollee's in network benefits. The Plan denied your request. 
The Plan says that precertification/notification/authorization/pre-treatment exceeded. 
 
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 has not substantiated their reason to continue to deny. The Plan has not 
provided documentation to support the denial that the services were exceeded. Therefore, we decided that the 
Plan has to pay for the unlisted molecular pathology services, Guardant360 (81479) provided January 18, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this inpatient care is medically 
reasonable and necessary. The Plan denied your request. The Plan says the enrollee does not require inpatient 
care and observation level of care would be more appropriate. 
 
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 pre-approve 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 the enrollee is a 74-year-old male with past medical history significant for chronic atrial fibrillation not on oral anticoagulant, diabetes mellitus, hypertension, chronic diastolic heart failure, and 
recent history of stroke back in December 2021. The documentation did not support hemodynamic instability 
or severe electrolyte disturbances that persists despite appropriate treatment beyond observation care, 
myxedema coma, thyroid storm, adrenal crisis, hypo-osmolality and new unexplained hypoxemia, new 
/uncontrolled diabetes insipidus, or gangrene that requires treatment beyond observation. The review has 
determined that the record did not show that at the time of inpatient admission the admitting physician 
reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 
does not have to pre-approve admission to an acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 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 laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on April 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 25 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 25 home health skilled nursing visits. You say that this is medically 
necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage have not 
been satisfied. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 25 home health skilled nursing visits. 
Our reviewer says that the requested home health skilled nursing visits are not medically reasonable and 
necessary for your condition. Our physician reviewer found the enrollee has a clean surgical wound without 
infection, drainage, tunneling or need for packing. Treatment is wash with normal saline, pat dry and dress with 
a non-sterile dressing. Sterile technique is not required. In this case, a clean surgical wound without infection, 
tunneling, excess drainage, need for packing or medicated dressing does not meet need for skilled nursing 
services per Medicare coverage rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 25 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 25 home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit (99213, J1040, 20610) provided on 
February 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that you received a referral from your PCP. 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 the outpatient visit (99213, J1040, 20610) 
provided on February 17, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
January 31, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the ambulance was 
necessary and should be billed as in-network. The Plan denied your request. The Plan says the enrollee was 
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 $260 copayment for each one-way ambulance trip.  
 
The enrollee was asked to pay a $260 copayment for the ambulance transportation. The ambulance 
transportation falls within the Ambulance Services benefit category. This means that the enrollee was 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 ambulance transportation provided on January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 22, 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 code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown lengthening (D4249) provided on February 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says crown lengthening (D4249) is not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for crown 
lengthening (D4249) provided on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special service procedures provided on November 29, 
2021, February 9, 2022, and February 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the special service procedures. You say that it was medically necessary for you 
to see the OON provider. 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. Additionally, the 
enrollee is contractually required to obtain this service from in-network providers. 
 
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 the special service procedures provided on 
November 29, 2021, February 9, 2022, and February 9, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance transportation provided on 
December 14, 2021, December 30, 2021, and December 31, 2021. 
 
You asked the Plan to waive the copayments for the ambulance transportation. You say that the Plan has 
always paid for this service. The Plan denied your request. The Plan says the proper copayments were applied 
for each date of service. 
 
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 $150 copayment for Ground Ambulance per date of service regardless of the number of trips. For 
each date of service there was a $150 copayment applied. With 3 dates of service the total copayment amount 
was $450 (3 dates of service x $150 copayment). 
 
  The enrollee has been asked to pay a $450 copayment for the ambulance transportation. The 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 the ambulance transportation provided on December 14, 2021, December 30, 
2021, and December 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for tissue debridement on January 03, 2022, to 
January 31, 2022. 
 
You asked the Plan to waive the copayment for tissue debridement. You say that the code is wrong, and you 
owe nothing. The Plan denied your request. The Plan says the cost-sharing you are being charged is 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 $165 
copayment for Medicare-covered outpatient admission to an outpatient hospital facility. Outpatient surgery 
includes any procedure performed in an ambulatory surgical center or hospital outpatient department, including 
diagnostic tests such as colonoscopies, endoscopies and minor procedures.  
 
You have been asked to pay a $165 copayment for each visit for tissue debridement. There were 3 visits, 
resulting in a total cost-sharing amount of $495.Tissue 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 waive the copayment for tissue debridement on January 03, 2022, to January 31, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist brace (L3916) provided February 28, 2022. 
 
You asked the Plan to pay for the wrist brace. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case.  The medical record does not state that the attending physician prescribed a right wrist/hand brace. 
The record does not state that the patient had wrist pain. Therefore, we decided that the Plan does not have to 
pay for a wrist brace (L3916) provided February 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility services from 
November 18, 2021, to November 22, 2021. 
 
You asked the Plan to waive the copayment for skilled nursing facility services from November 18, 2021, to 
November 22, 2021. You say that you are not responsible for this amount. The Plan denied your request. The 
Plan says you must a $160 per day copayment for days 21-45 in a skilled nursing facility. 
 
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 $160 
copayment per day for Skilled Nursing Facility (SNF) Care.  
 
You have been asked to pay an $800 per day copayment for skilled nursing facility services. Skilled nursing 
facility services fall within the Skilled Nursing Facility (SNF) 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 skilled nursing facility services from November 18, 2021, to November 22, 2021.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to correct and apply the proper copayment amount for an inpatient hospital stay 
provided from March 9, 2021, to March 11, 2021. 
 
You asked the Plan to lower the copayment for the inpatient hospital stay. You say that you do not agree with 
the copayment that was applied. The Plan denied your request. The Plan says they reprocessed the claim and 
applied the proper copayment to the service that was rendered. 
 
We decided that the Plan has to change the copayment to the proper amount for the inpatient hospital stay 
provided from March 9, 2021, to March 11, 2021.   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 $160 
copayment per day for days 1-5 per admission for each medically necessary inpatient stay. Inpatient hospital 
care starts the day you are formally admitted to the hospital with a doctors order. The day before you are 
discharged is your last inpatient day. The total copayment amount the Plan applied was $480 ($160 copayment 
per day x 3 days). The day the enrollee was admitted was March 9, 2021, and the date of discharge was March 
11, 2021. The EOC states the day before discharge is your last inpatient day; therefore, the total copayment 
amount applied should be $320 ($160 copayment per day x 2 days). 
 
Therefore, we decided that the Plan has to change the copayment amount to $320 for the inpatient hospital stay visit 
provided on March 9, 2021, to March 11, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $250 copayment for ambulance transportation services 
provided on March 25, 2022. 
 
You asked the Plan to waive the $250 copayment for ambulance transportation services provided on March 25, 
2022. You say that you are not responsible to pay this copayment. The Plan denied your request. The Plan says 
you are responsible for a $250 copayment for each separate ambulance service. 
 
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 Ambulance Services.  
 
You have been asked to pay a $250 copayment for ambulance services provided on March 25, 2022. 
Ambulance transportation services fall 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 $250 copayment for ambulance transportation services provided on March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an annual wellness visit (G0439) provided 
on December 10, 2021. 
 
You asked the Plan to waive the copayment for the annual wellness visit. You say that the services should be 
covered as you disagree with the charges and have never had a copayment for these services before. The Plan 
denied your request. The Plan says the cost-sharing applied correctly based on the services provided, the 
copayment assessed because services were rendered out-of-network. 
 
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 $25 
copayment for out-of-network annual routine physical exam.  
 
  You have been asked to pay a $25 copayment for the annual wellness visit rendered by an out-of-network 
provider. 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 annual wellness visit (G0439) provided on 
December 10, 2021.