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

 
We decided that the Plan does not have to reduce the copayment for a cystourethroscopy provided on 
September 23, 2021. 
 
You asked the Plan to reduce the copayment for a cystourethroscopy. You say that you did not have a minor 
procedure at a hospital or emergency room. You also say that your benefits plan indicates that diagnostic tests 
and procedures for in-network services is a $30 copayment, not $350. 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 in-network outpatient surgery at a hospital.  
 
 A cystourethroscopy is considered a surgical procedure. You have been asked to pay a $350 copayment for a 
cystourethroscopy. A cystourethroscopy falls within the Outpatient Surgery and Other Medical 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 a cystourethroscopy provided on September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive BRCA testing. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the record does not show a personal history of cancer. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the services, is being requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve 
comprehensive BRCA testing.
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 
leg joint provided on October 19, 2021. 
 
You asked the Plan to waive the copayment for an MRI. You say that you cannot afford the 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 $150 
copayment for high-tech radiology services, including MRIs.  
 
You have been asked to pay a $150 copayment for an MRI. 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 leg joint provided on October 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on September 2, 2021. 
 
You asked the Plan to pay for the services provided. You say that the testing can eliminate the need to give 
antibiotics. The Plan denied your request. The Plan says the testing exceeds the enrollee's medical needs. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. In this case, the medical records provided do not document the physicians 
intent for the testing to be ordered. The test at issue appears to have been requested solely for screening 
purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does 
not have to pay for the lab testing services provided on September 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing admission. 
 
You asked the Plan to pre-approve the skilled nursing admission. You say that the enrollee had a surgery and 
needs professional help such as physical therapy. You also say that the enrollee does not have full control of 
her body and needs help to become stronger. The Plan denied your request. The Plan says the criteria for an 
admission to a skilled nursing facility (SNF) have not been met. 
 
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 the skilled nursing admission. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not 
have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing 
and/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 the skilled nursing admission have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a skilled nursing admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Ultra test strips. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that diabetic test strips are covered for beneficiaries 
with diabetes. 
 
We looked at the file and Medicare rules. The file shows that you do not have a diagnosis of diabetes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve OneTouch Ultra test strips.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 17, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that medical records are attached, and the claim 
should be processed toward payment. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment.  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 the laboratory services provided on January 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (99100) provided on June 4, 2021. 
 
You asked the Plan to pay for the anesthesia (99100). You say that the services rendered were based on the 
patient condition. You say that the coding specialist determined the procedure was essential and coded 
appropriately. The Plan denied your request. The Plan says bundled services are not eligible for separate 
payment. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).  
We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B. This means that CPT code 99100 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the anesthesia (99100) have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia (99100) provided on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transforaminal epidural steroid injection for the 
enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no record of active participation in a course of supervised physical therapy 
lasting more than four weeks for the current pain. 
 
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 the injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the most recent injection on 11/22/21 provided no relief. In addition, In addition, there is no record of the 
enrollee being in a supervised physical therapy, an active rehabilitation program, exercise program, or 
functional restoration program, while being treated with injections, which is required. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transforaminal epidural steroid injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM), provided on October 
25, 2021. 
 
You asked the Plan to pay for a CGM. You say that the item was medically necessary. The Plan denied your 
request. The Plan says the member obtained this item through an unsolicited telephone call by the supplier. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of a CGM have not 
been met. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM), 
provided on October 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
July 15, 2021, to July 28, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the claim is still 
processing and should not be charged to your father. You also say that the insurance should cover most of this 
bill. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $285 copayment per day for days 1-6 for an inpatient hospital stay. The Plan contract also says that 
there is no charge for days 7-90. 
 The records show this claim for an inpatient hospital stay from July 15, 2021, to July 28, 2021, processed on 
October 13, 2021. The enrollee has been asked to pay a total of $1, 710, which is a $285 copayment for days 1-
6 for an inpatient hospital stay ($285 copayment x 6 days = $1,710). There is no charge for days 7-90. An 
inpatient hospital stay falls within the Inpatient Hospital Care benefit category. This means that the enrollee has 
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for an inpatient hospital stay provided from July 15, 2021, to July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM), provided on June 11, 
2021. 
 
You asked the Plan to pay for a CGM. You say that the item is medically necessary. The Plan denied your 
request. The Plan says there is evidence of misrepresented 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 a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. the records submitted do not show the member treating physician ordered this item or that the item is medically necessary. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a continuous glucose monitor (CGM), provided on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) and a duplex scan of extracranial 
arteries (93880) provided on May 25, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and a duplex scan of extracranial arteries. You say that your 
provider saw this patient for a consultation and a test on May 25, 2021, and you are appealing with supporting 
records. The Plan denied your request. The Plan says upon review, an authorization was not obtained prior to 
the services being rendered and the provider is not participating with the Plan. The Plan also says that the 
member's daughter self-referred the member to the provider, and the services rendered were not Plan directed 
care. The Plan also says that it was determined that the services were not urgent or emergent in nature. 
 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 (99204) and a duplex scan of 
extracranial arteries (93880) provided on May 25, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Targeted genomic sequence analysis panel (81455) 
provided on August 25, 2021. 
 
You asked the Plan to pay for code 81455. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Medicare says that genetic testing submitted under code 81455 will 
be denied as not medically necessary as it is unlikely to impact therapeutic decision-making in the clinical 
management of the enrollee. Therefore, we decided that the Plan does not have to pay for the Targeted genomic 
sequence analysis panel (81455) provided on August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intravenous moderate 
(conscious) sedation, first 15 minutes (D9239), intravenous moderate (conscious) sedation, each subsequent 
15-minute increment (D9243) and four (4) extractions (D7210) provided on April 7, 2021, to June 28, 2021, 
with an out-of-network (OON) provider. 
 
You asked the Plan to pay for a limited oral evaluation, intravenous moderate sedation and extractions. You say 
that you do not agree with the denial. The Plan denied your request. The Plan says there is no coverage for 
limited oral evaluations and intravenous moderate sedation. Additionally, extractions are covered twice per 
calendar year with the enrollee responsible for 55% when the services are performed by an OON provider. The 
Plan also says the claims were processed correctly based on the enrollees benefits at the time services were 
rendered. 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. 
 
We looked at the file and Medicare rules. The EOC confirms that you receive two extractions per calendar 
year. The EOC also confirms that if you receive extraction from an OON provider, you are responsible for 55% 
of the cost. The records show you had 6 extractions with an OON provider. The Plan paid for 2 extractions; 
therefore, you are responsible for the remaining 4 extractions that were done. The EOC also confirms what 
services are covered. A limited oral evaluation and intravenous sedation is not a covered benefit with the 
enrollees plan; therefore, these services are not covered. Based on this information, we decided that the Plan's 
rules for coverage of a limited oral evaluation, intravenous moderate sedation and teeth extractions have not 
been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), 
intravenous moderate (conscious) sedation, first 15 minutes (D9239), intravenous moderate (conscious) 
sedation, each subsequent 15-minute increment (D9243) and four (4) extractions (D7210) provided on April 7, 
2021, to June 28, 2021, with an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
June 29, 2021, to July 1, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were unaware there 
would be an extra $200 charge. 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 for an inpatient hospital stay.  
 
You have been asked to pay a $200 copayment for an inpatient hospital stay. An inpatient hospital stay 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 hospital stay provided from June 29, 2021, to 
July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 16, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship between the 
enrollee and ordering physician. 
 
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 the office visit (99202) provided on 
February 16, 2021. have been met. Specifically, the documentation submitted does not include sufficient 
clinical information. Additionally, there is no evidence of an established relationship between the enrollee and 
ordering physician. Therefore, we decided that the Plan does not have to pay for the office visit (99202) 
provided on February 16, 2021.