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

 
We decided that the Plan does not have to pay for lab testing provided on March 31, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. 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 lab testing provided on 
March 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional care in observation. 
 
You asked the Plan to pre-approve additional care in observation. You say that the records provided support the 
request for a continued observation care. The Plan denied your request. The Plan says observation care is only covered for 48-hours. The Plan says that if more hospital care is needed, the medical team could transfer the 
enrollee to another level of care. 
 
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 additional care in observation. Our 
reviewer says that additional care in observation is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee was diagnosed with an acute viral upper respiratory infection 
and failure to thrive who was admitted to observation on December 5, 2022. As of December 7, 2022, she was 
hemodynamically stable and no longer required any observation level of care services. The review has 
determined that continued care at the observation level was not considered medically reasonable or necessary. 
There was no documentation of plans for discharge or transfer to inpatient status. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional care in observation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional care in observation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on September 27, 
2022. 
 
You asked the Plan to pay for the dental services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 12, 2021, April 
13, 2022, and September 12, 2022. Therefore, we decided that the Plan does not have to pay for the limited oral 
exam (D0140) provided on September 27, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0483 provided on July 5, 2021. 
 
You asked the Plan to pay for procedure code G0483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not supported. 
 
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 G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the records support that 22 or 
more drug classes have been tested, including Amphetamines, Barbituates, Benzodizepines, Buprenorphine, 
Cannabinoids-natural, Cannabinoids-synthetic, Cocaine, Fentanyls, Gabapentin-non-blood, Heroin metabolite, 
Methadone, Methylenedioxyamphetamines, Methylphenidate, Opiates, Opioids and opiate analogs, 
Oxycodone, Phencyclidine, Pregabalin, Sedative Hypnotics (non-benzodiazepines0, Skeletal muscle relaxants, 
Stimulants-synthetic, Tapentadol, and Tramadol. Based on this information, we decided that Medicare rules for 
coverage of procedure code G0483 have been met. Therefore, we decided that the Plan has to pay for procedure 
code G0483 provided on July 5, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will need medical oversight for their 
medical conditions. The Plan denied your request. The Plan says that the IRF care is not medically necessary, 
and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility or home with home 
health rehabilitation. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the documentation shows that the enrollee has complex functional impairments requiring physical 
therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) for spasticity, neurologic 
weakness and clonus. The enrollee's evaluating therapists (PT, OT, SLP) all recommend intense therapy. The 
clinical documentation shows active medical issues including seizures, hypoxia, spasticity which means the 
enrollee would be expected to require continued inpatient hospitalization with an interdisciplinary approach to 
rehabilitation care. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on August 2, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you disagree with the 
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 $250 
copayment for outpatient surgery/Medicare-covered outpatient surgery.  
 
You have been asked to pay a $250 copayment for outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-covered outpatient surgery 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 outpatient surgery provided on August 2, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on September 23, 2022. 
 
You asked the Plan to pay for the mental health services. You say that the records provided support medical 
necessity. 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 the mental health 
services provided on September 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for inpatient hospital care provided 
from September 10, 2022, to September 14, 2022. 
 
You asked the Plan to waive or reduce the copayment for the inpatient hospital care. You say that the 
copayment seems high considering the Plan details. 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 per day for days 1-5 for inpatient hospital care.  
 
 
  The file shows you were in the hospital for 4 days from September 10, 2022, to September 14, 2022 (no 
copayment for the discharge date). Therefore, you have been asked to pay a $350 copayment per day for 4 days 
of inpatient hospital care. The total for the stay is $1,400 ($350 copayment x 4 days = $1,400). This 
item/service 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 or 
reduce the copayment for inpatient hospital care provided from September 10, 2022, to September 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for MRI provided on August 04, 2022. 
 
You asked the Plan to pay for MRI. You say that you are requesting reconsideration. 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 MRI provided on 
August 04, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
July 22, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you disagree with the 
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 $250 
copayment for outpatient hospital services/surgery Services.  
 
You have been asked to pay a $250 copayment for outpatient hospital services. However, you are being asked 
to pay $132.84 which is less than the required amount. This item/service falls within the outpatient hospital 
services/surgery Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient 
hospital services provided on July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service July 6, 2022. 
 
You asked the Plan to pay for procedure code 11721. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 11721 is bundled into 
payment for code 11055.  
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, we have confirmed that code 11721 
is a column II code to column I code 11055. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 11721 billed for date of service July 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device placement surgery (22869). 
 
You asked the Plan to pre-approve a Vertiflex device placement surgery. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
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 a Vertiflex device placement surgery. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this service is considered experimental and more research is needed to show it 
safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex device placement surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Vertiflex device placement surgery (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 29, 
2022, to July 5, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
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 $325 
copayment for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $325 copayment for days 1-5 for inpatient hospital care. The total amount you 
are being asked to pay $1,300 ($325 x 4days = $1,300). 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 
inpatient hospital care provided on June 29, 2022, to July 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
May 24, 2021, to May 28, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you don't believe you 
should be liable for the remaining 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 per day, days 1-5, each time you are admitted to an acute care hospital. 
 
You have been asked to pay a $1400 copayment for the inpatient hospital stay ($350 x 4 days = $1400). This 
item/service 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 the inpatient hospital stay provided from May 24, 2021, to May 28, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve diabetic shoes (A5500) and inserts (A5512). 
 
You asked the Plan to pre-approve the diabetic shoes (A5500) and inserts (A5512). You say that the shoes and 
insoles are medically necessary to prevent exacerbation of your current foot condition. The Plan denied your 
request. The Plan says that the diabetic shoes and inserts are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that health plans must ensure that services are provided 
when 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 the diabetic shoes (A5500) and inserts 
(A5512). Our reviewer says that the service is medically necessary. Our physician reviewer found the notes in 
the case support that the enrollee is an insulin-dependent diabetic, is cared for by a primary care physician, and 
also demonstrates bilateral hammertoes, pre-ulcerative areas, peripheral neuropathy, corns and calluses. The 
requested extra depth therapeutic shoes plus 3 pair of heat moldable inserts are medically reasonable and 
necessary. 
 
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 diabetic shoes (A5500) and inserts (A5512) have been met. Therefore, we 
decided that the Plan has to pre-approve diabetic shoes (A5500) and inserts (A5512).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0150) and intraoral radiographic images 
(D0210) provided on August 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know about the 3-year limit. The 
Plan denied your request. The Plan says your benefit for the requested items or services has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on the date of service of February 13, 
2020. Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0150) and intraoral 
radiographic images (D0210) provided on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
September 16, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you disagree with the 
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 $110 
copayment for outpatient hospital services/basic radiological services.  
 
You have been asked to pay a $110 copayment for outpatient hospital services. However, you are only being 
asked to pay $101.55 which is less than the required amount. This item/service falls within the outpatient 
hospital services/basic radiological services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for outpatient hospital services provided on September 16, 2022.