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

 
We decided that the Plan does not have to pay for the unlisted Molecular Pathology procedure (81479) 
provided July 12, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that you believe that the evidence supporting the 
use of Cxladder triage test as a medically necessary diagnostic service is well established. The Plan denied your 
request. The Plan says the records do not meet the requirements for approval 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee is an 82 year old male with cancer of the 
pancreas. The review has determined that the medical records provided do not meet the medical necessity 
requirements listed in the LCD for Medicare coverage. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the unlisted Molecular Pathology procedure (81479) provided July 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $25 copayment for physical therapy services rendered on 
November 3, 2021. 
 
You asked the Plan to waive the $25 copayment for physical therapy services rendered on November 3, 2021. 
You say that you should not be responsible for this copayment because you did not receive these services. The 
Plan denied your request. The Plan says you are responsible to pay a $25 copayment for in-network physical 
therapy visits. 
 
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 Outpatient Rehabilitation Services.  
 
 
 
 
 
 You have been asked to pay a $25 copayment for physical therapy services. Physical therapy services fall 
within the Outpatient Rehabilitation Services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. Records submitted support that physical therapy services 
were rendered to you on November 3, 2021. 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 $25 copayment 
for physical therapy services rendered on November 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcatheter aortic valve replacement (TAVR) provided 
on December 3, 2021, billed with code 33361-62-Q0. 
 
You asked the Plan to pay for the TAVR procedure as billed. You say that this was denied incorrectly as the 
services were medically necessary and billed correctly. The Plan denied your request. The Plan says the clinical 
trial number is not reported on this claim as required. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for payment of services covered under 
CED must include the clinical trial number, or they will be returned as unprocessable.  
We looked at the file and Medicare rules. Review of this claim does not show that the clinical trial number was 
reported. Based on this information, we decided that Medicare rules for coverage of the TAVR procedure as 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the transcatheter aortic 
valve replacement (TAVR) provided on December 3, 2021, billed with code 33361-62-Q0.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on March 14, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you submitted documentation for review. 
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 specialist office visit provided on March 14, 
2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
December 29, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you fell leaving the ER and you feel 
you received little to no treatment. 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency 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 emergency room (ER) visit 
provided on December 29, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient stay provided from November 12, 2021, to November 14, 
2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this stay has been approved as 
outpatient surgery/observation level of care. The Plan denied your request. The Plan says that the medical 
records support the medical necessity of this 2 day emergency room admission. 
 
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 the enrollee received appropriate treatment including cholecystectomy, with no evidence of 
significant complication. The review has determined that the record show that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care (including 
earlier ED 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 
has to pay for the inpatient stay provided from November 12, 2021, to November 14, 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 waive the copayment the skilled nursing facility (SNF) services 
provided from February 1, 2022, through February 25, 2022. 
 
You asked the Plan to waive the copayment the SNF services. You say that you would like this copayment 
waived based on the quality of care you received. The Plan denied your request. The Plan says this copayment 
has 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 a $0 
copayment each day for days 1-20 and a $188 copayment each day for days 21-100 for skilled nursing facility 
care.  
 
 
 
 
 You have been asked to pay a total cost share of $1504 (8 days after day 20 x $188 copayment). This care falls 
within the skilled nursing facility 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 the 
skilled nursing facility (SNF) services provided from February 1, 2022, through February 25, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on November 22, 2021. 
 
You asked the Plan to pay for psychotherapy. You say that the physician provided medically necessary services 
in good faith and the services meet professional recognized standards of healthcare. You say that the claim 
should be processed for payment. The Plan denied your request. The Plan says the provider must attempt to 
consult the attending or primary care physician about the services furnished. 
 
  The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on November 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from August 31, 2020, 
through September 5, 2020, billed with secondary diagnosis code E87.2. 
 You asked the Plan to pay for the inpatient care as billed. You say that it is felt that this claim was billed at the 
proper DRG. The Plan denied your request. The Plan says the diagnosis code E87.2 is not supported. As such, 
the DRG as billed is not appropriate. 
 
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, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code E87.2, defined as 
acidosis. 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 care as billed. Our 
reviewer says that the documentation does not support reporting code E87.2 as a secondary diagnosis for this 
admission. Our physician reviewer found according to coding guidelines and documentation in the medical 
record, this condition did not qualify for reporting. Documentation supported an admission for gastric ulcer 
with perforation. From the information that was received, documentation was inconsistent/unclear regarding a 
diagnosis of acidosis. Even though lactic acidosis is only documented in the emergency department provider 
interpretation of abnormal lab results, supporting medical record documentation was not found within the 
record. The patient's initial lactic acid on August 31, 2020, was 1.7 at 3:05am. This increased to 4.4 at 4:24am 
and decreased to 0.9 on September 01, 2020. The progress note on September 01, 2020 stated, "lactate 
cleared." Documentation of a reason or suspected cause of lactic acidosis was not found. The review has 
determined that the medical records did not support the billing of acidosis (E87.2).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital care provided from August 31, 2020, through September 5, 2020, billed with 
secondary diagnosis code E87.2.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the visits. You say that you would like the continued PT visits to be 
approved to help the patient return to a functional, minimal pain level quality of life. The Plan denied your 
request. The Plan says this request is 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 the visits. 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 the additional requested therapy generally is not accepted as specific and 
effective therapy for the patients condition beyond what was approved by the health plan. The patient has had 
prior therapy and the documentation does not reveal that the patient requires the unique skills of a professional 
therapist to safely and effectively provide treatment, that the services can be safely and effectively performed 
only by a therapist, or by or under the supervision of a therapist. The requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow 
further deterioration. The patient can transition to an independent home exercise program. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care (PCP) office visit provided 
on February 21, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were seen for an annual 
wellness visit and should not be charged. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment for each PCP visit.  
 
The record shows that you were seen for a specific problem for nasal issues. Therefore, you have been asked to 
pay a $5 copayment for the office visit. The office visit falls 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 a 
primary care (PCP) office visit provided on February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for outpatient surgery provided on January 3, 
2022. 
 
You asked the Plan to waive the deductible for outpatient surgery. You say that you wanted to have this 
procedure in 2021 but you were not able to be seen then. The Plan denied your request. The Plan says the 
deductible applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1000 deductible which applies to outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies 
to Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers. This cost sharing is a contractual obligation that had not been met at the time outpatient surgery was 
received on January 3, 2022. Therefore, we decided that the Plan does not have to waive the deductible for 
outpatient surgery provided on January 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive your $75 copayment for a breast ultrasound performed on 
February 2, 2022. 
 
You asked the Plan to waive your $75 copayment for a breast ultrasound performed on February 2, 2022. You 
say that this should be covered. The Plan denied your request. The Plan says you are responsible to pay a $75 
copayment for an in-network ultrasound. 
 
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 $75 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $75 copayment for breast ultrasound. A breast ultrasound 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 your $75 copayment for a breast ultrasound performed on February 2, 2022.  Please note, the record indicates that you paid a $45 copayment. You are responsible for the remaining $30 to 
reach the required copayment of $75 as listed in your contract with the Plan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 27, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you have submitted medical records to 
support payment. The Plan denied your request. The Plan says unauthorized, non-plan 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 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 medical services provided on January 27, 2022 by 
an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services provided on 
April 15, 2021. 
 
You asked the Plan to pay for hospital discharge day management services. The Plan denied your request. The 
Plan says the member was enrolled in Hospice with no revocation. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital discharge day management services provided on 
April 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital services provided to the enrollee 
from November 1, 2021, to November 4, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says this admission can be approved for observation status, since the 
procedure is not inpatient only. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was electively admitted for anterior and posterior colporrhaphy. The 
surgery and post-operative course were unremarkable. The procedure does not require inpatient level of care 
services. 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 ED 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 not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital services provided to the enrollee from November 1, 2021, 
to November 4, 2021.