Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from May 6, 2022, to 
May 13, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted supporting documentation for reconsideration of the DRG adjustment. The Plan denied your request. The Plan says after a thorough review of all the information in the submitted medical record, the review did not 
find sufficient documentation to clinically validate the diagnosis of J96.01, acute respiratory failure with 
hypoxia. 
 
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 DRG 469. 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 hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that a transient episode of hypoxia while the enrollee slept and was monitored does not fulfill criteria for acute 
respiratory failure, especially in setting of chronic obstructive pulmonary disease (COPD) exacerbation.  
 
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 inpatient hospital services rendered from May 6, 2022, to May 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on October 24, 2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you do not agree with the cost 
sharing amount. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for in-network lab services only when provided in an outpatient hospital facility. 
 
You have been asked to pay a $40 copayment for lab services. This item/service falls within the in-network lab 
services only when provided in an outpatient hospital facility 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 lab services provided on October 24, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the heart. 
 
You asked the Plan to pre-approve CT scan of the heart. You say that the enrollee has unexplained dilation of 
their right vertical and right atrium. You say that a CT scan would be very helpful in making sure the enrollee 
does not have partial anomalous pulmonary veins causing it. The Plan denied your request. The Plan says that a 
CT scan of the heart is not medically necessary. 
 
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 CT scan of the heart. Our reviewer says 
that the requested CT scan of the heart is medically necessary. Our physician reviewer found that the enrollee 
has a moderately elevated right ventricle systolic pressure, right heart dilation, and moderate tricuspid 
regurgitation. The enrollee can benefit from this study to clarify the etiology and find the potentially 
correctable anomalous Pulmonary vein malformation to prevent right heart failure and pulmonary 
hypertension. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of the heart have been met. Therefore, we decided that the Plan has to 
pre-approve a CT scan of the heart.  
 
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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the enrollee's care needs can be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have complex nursing or rehabilitation needs. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mammography provided on December 15, 2022. 
 
You asked the Plan to pay for the mammography. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that in order to process this claim the Plan needs an Explanation of 
Benefits from the primary insurance carrier. The Plan says that the Plan has tried to obtain the Explanation of 
Benefits from the primary insurance, but it was not yet received. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has tried to 
obtain the Explanation of Benefits from the primary insurance. As the secondary insurer, the Plan cannot be 
held responsible for the mammography until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for a mammography provided on December 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided September 11, 2022 to 
September 26, 2022. 
 
You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the home health services are not supported in the documentation. Specifically, the claim did not 
include the required Federal Information Processing 
Standards (FIPS) location code. Based on this information, we decided that Medicare rules for coverage of the 
home health services have not been met. Therefore, we decided that the Plan does not have to pay for home 
health services provided September 11, 2022 to September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the dermatology specialist services provided 
on August 24, 2022. 
 
You asked the Plan to waive the deductible for the specialist services. You say that you believe the wrong code 
was used on this claim. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible which applies to out-of-network specialist services.  
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $1,000 deductible which applies to out-of-network specialist services. This cost sharing is a contractual 
obligation that had not been met at the time the specialist services were received on August 24, 2022. Therefore, we decided that the Plan does not have to waive the deductible for the dermatology specialist 
services provided on August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 12, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration, stating no 
authorization was obtained. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on January 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy injections provided on 
October 14, 2022, and October 28, 2022. 
 
You asked the Plan to waive the coinsurance for the chemotherapy injections. You say that you were not told 
that you would have a coinsurance. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each in-network Medicare Part B chemotherapy drug.  
 
You have been asked to pay 20% coinsurance for the chemotherapy injections. These items/services fall within 
the Medicare Part B prescription drugs benefit category.  Date of service Code Allowed Amount 20% Coinsurance 
October 14, 2022 J9132 $8,225.10 $1,645.02 
October 14, 2022 J2930 $5.41 $1.15 
October 18, 2022 J9132 $8,225.10 $1,645.02 
October 18, 2022 J2930 $5.41 $1.15 
 
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 coinsurance for the chemotherapy injections provided on October 14, 2022, 
and October 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the vein wound compression bandage 
application provided on November 03, 2022. 
 
You asked the Plan to reduce the copayment for the vein wound compression bandage application. You say 
that this was not a surgery and should have a $45 copayment. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for in-network outpatient surgery at an outpatient hospital facility. 
 
You have been asked to pay a $350 copayment for the vein wound compression bandage application. This 
item/service falls within the in-network outpatient surgery at an outpatient hospital facility 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. According to Medicare the 
vein wound compression bandage application (code 29581) is considered a surgical procedure. However, since 
the allowed amount is less than the standard copayment, you only owe $144.69. Therefore, we decided that the 
Plan does not have to reduce the copayment for the vein wound compression bandage application provided on 
November 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia provided on September 19, 2022. 
 
You asked the Plan to pay for the anesthesia. You say that the surgery had nothing to do with hospice. 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 anesthesia provided on September 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient hospital office visits 
provided from June 8, 2021, to December 13, 2022. 
 
You asked the Plan to waive the copayments for the office visits. You say that you were told there was a $0 
copayment when you signed up for the Plan. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for in-network outpatient hospital services.  The record shows that the office visit was provided at an outpatient hospital. You have been asked to pay a $10 
copayment for each office visit. These items/services fall within the outpatient hospital services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayments for the outpatient hospital office visits provided 
from June 8, 2021, to December 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the outpatient cardiac surgery provided on 
January 19, 2023. 
 
You asked the Plan to reduce the cost share for the outpatient surgery. You say that you should only have to 
pay the deductible amount. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $525 in-network deductible which applies to in-network outpatient surgery. The Plan contract also says that you must pay 10% coinsurance after meeting the deductible for in-
network outpatient surgery. 
 
The item or service you asked the Plan to reduce the cost share for falls within the outpatient surgery benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $525 in-
network deductible which applies to in-network outpatient surgery. You have been asked to pay $507.07 
towards your in-network deductible. This cost sharing is a contractual obligation that had not been met at the 
time the outpatient surgery was received on January 19, 2023. 
 
The record shows your out-of-pocket maximum was met during the processing of this claim. You have been 
asked to pay $1,740 coinsurance for the in-network outpatient cardiac surgery. This item/service falls within 
the outpatient surgery benefit category. You have been asked to pay a total of $2,247.07 ($507.07 deductible + 
$1,740 coinsurance = $2,247.07). 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 cost share for the 
outpatient cardiac surgery provided on January 19, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on September 24, 2022. 
 You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says the services 
should be billed under Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 9, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance 
services provided on September 24, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown - porcelain/ceramic tooth #29 (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that this is the third time in two years the 
enrollee has lost the filling. You also say that the tooth was otherwise asymptomatic. The Plan denied your 
request. The Plan says that your benefit for the requested item or service has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve a crown - porcelain/ceramic tooth #29 
(D2740).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the laboratory services provided on January 
13, 2023. 
 
You asked the Plan to waive the deductible for the lab services. You say that you were expecting a $10 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $525 in-network deductible which applies to in-network lab services. 
The Plan contract also says that you must pay a $10 copayment after meeting the deductible for in-network lab 
services. 
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests and therapeutic services benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $525 in-network deductible which applies to in-network lab services. This cost sharing 
is a contractual obligation that had not been met at the time the lab services were received on January 13, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the laboratory services provided 
on January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 12, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on December 12, 2022.