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

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs provided on January 28, 
2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that the doctor never told you about the 
charges. The Plan denied your request. The Plan says the coinsurance applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B non-chemotherapy prescription drugs.  
 
You have been asked to pay $254.46 which is 20% of the allowed amount for Part B drugs. The allowed 
amount is $1,272.30 (20% x $1,272.30= $254.46). Part B drugs falls within the Medicare Part B Prescription 
Drugs 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 coinsurance for Part B drugs provided on 
January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on January 17, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for anesthesia services. You say that anesthesia services must be linked to the 
rendering facility. You say the enrollee cannot choose their anesthesiologist and should not be penalized with 
an underpaid claim. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
anesthesia services. We found no exception that would require the Plan to pay for the anesthesia services. The 
records provided for review do not show that the anesthesia services at issue were urgent or emergent. 
Therefore, we decided that the Plan does not have to pay for anesthesia services provided on January 17, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided on February 11, 
2022. 
 
You asked the Plan to waive the copayment for an injection. You say that you feel this should be covered 
because the provider billed it under an outpatient procedure. You also say that you only went there for an 
injection and never had surgery. The Plan denied your request. The Plan says you have been charged the 
correct copayment 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 $100 
copayment per day for outpatient procedures and services, including but not limited to diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical 
center. 
 You have been asked to pay a $100 copayment for an injection. The injection falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an injection provided on February 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
services you are requesting do not meet the requirements for approval. 
 
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 enrollee has ongoing post-acute medical needs, particularly her ventilator. She does not require intensive rehabilitation. Even with the ventilator she is functioning at a home care level. She has 
neither complex nor intensive rehabilitation needs. She does not require frequent physiatry oversight. She has 
chronic ventilator and medical needs not rehabilitation needs. Criteria per chapter 1 of the Medicare benefit 
manual have not been met. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections provided on January 25, 2022. 
 
You asked the Plan to waive the copayment for injections. You say that you weren't charged this before when 
you had the shots at a providers office. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $275 
copayment for all other outpatient services not provided in an ambulatory surgical center. 
 
You have been asked to pay $275 copayment for injections. Injections fall within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for injections provided on January 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from November 7, 2021, through 
November 11, 2021, at DRG 189. 
 
You asked the Plan to pay for inpatient services at DRG 189. You say that diagnosis code J96.01 is supported 
by the physician documentation and the information in the enrollee's medical record. You say that you disagree 
with the DRG reassignment. The Plan denied your request. The Plan says diagnosis code J96.01 remains not 
supported. 
 
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 with principal diagnosis code J96.01, defined as acute respiratory 
failure with hypoxia. 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 inpatient services at DRG 
189. Our reviewer says that the documentation does not support diagnosis code J96.01. Our physician reviewer 
found while the documentation partially supports acute respiratory failure, the medical record does not include 
evidence of treatment consistent with acute respiratory failure.  
 
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 services provided from November 7, 2021, through November 11, 2021, at DRG 189.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (36415, 46750, 57250, 57267, 57280, 
57288, 80053, 81001, 82962, 85025, C1762, C1771, C1781, J0330, J0690, J1100, J1885, J2270, & J3010) 
provided March 2, 2022 to March 3, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the billed services are not separately payable. 
 
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 find that CPT codes 36415, 46750, 57250, 57267, 57280, 57288, 80053, 81001, 82962, 85025, C1762, 
C1771, C1781, J0330, J0690, J1100, J1885, J2270, & J3010 are not supported in the medical record. 
Specifically, the codes billed were provided on the same date as an inpatient procedure and are not separately 
payable. Based on this information, we decided that Medicare rules for coverage of the surgical services have 
not been met. Therefore, we decided that the Plan does not have to pay for surgical services (36415, 46750, 57250, 57267, 57280, 57288, 80053, 81001, 82962, 85025, C1762, C1771, C1781, J0330, J0690, J1100, 
J1885, J2270, & J3010) provided March 2, 2022 to March 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on March 10, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you were unaware you would 
have a copayment. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $150 
copayment for surgical services in an outpatient hospital setting.  
 
You have been asked to pay $150 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery provided 
on March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on March 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that you are a participating provider and do not need 
pre-authorization. You say the services was medically necessary. The Plan denied your request. The Plan says 
no prior authorization was obtained. 
 
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 did not pre-approve the 
drug testing. We found no exception that would require the Plan to pay for the drug testing. The records 
provided for review do not show that the drug testing was urgent or emergent. Therefore, we decided that the 
Plan does not have to pay for drug testing provided on March 15, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from April 1, 2022, to 
April 26, 2022. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you cannot afford this charge. The 
Plan denied your request. The Plan says the copayment was applied 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, for days 
1 through 20: a $0 Copay and  for days 21 through 100: a $188 copayment per day.  
 
You have been asked to pay $3,948 ($188 copay x 21 days) for the SNF stay. The SNF stay falls within the 
Skilled Nursing Facility (SNF) Care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
skilled nursing facility (SNF) stay provided from April 1, 2022, to April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on March 24, 
2022. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that your primary care doctor was 
busy and couldn't see you for a few weeks and you needed to be seen sooner. The Plan denied your request. 
The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $50 
copayment for each Medicare-covered urgent care facility visit.  
 
You have been asked to pay $50 copayment for urgent care visit. Urgent care visits fall within the Urgently 
Needed 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 urgent care visit 
provided on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on December 9, 
2021. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you went to urgent care to get 
your COVID-19 booster shot which you thought was free and didn't realize you would be charged for the office 
visit. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $50 
copayment for each covered office visit to other providers for urgently needed services.  
 
 
 
 You have been asked to pay $50 copayment for urgent care visit. Urgent care visits fall within the Urgently 
Needed 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 urgent care visit 
provided on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on May 16, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you thought you would only 
have a $10 copayment. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $45 
copayment for each office visit or telehealth visit to a specialist.  
 
You have been asked to pay $45 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors 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 specialist office visit provided on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient consultation provided on January 14, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient consultation. You say that the facility should have obtained the 
prior authorization. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
inpatient consultation. We found no exception that would require the Plan to pay for the inpatient consultation. 
The records provided for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the inpatient consultation provided on January 14, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 1, 2021, billed 
with codes 81191, 81317, 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301 and 
81311. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on November 1, 2021, billed with codes 81191, 81317, 81321, 81206, 81210, 81235, 81272, 81275, 81276, 
81292, 81295, 81298, 81301 and 81311.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lens (V2200) provided on March 22, 2022. 
 
You asked the Plan to pre-approve the lens. You say that you believe that you should be reimbursed the $96 
that you paid out of pocket because no one advised that you would not be reimbursed. The Plan denied your 
request. The Plan says your benefit maximum has been met. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $150 vision allowance every two years for routine eyewear. 
 
We looked at the file and the Plan's rules. The record shows that you were last reimbursed for lenses on 
September 26, 2020, and you would not be eligible for coverage of lenses until September 26, 2022. Based on 
this information, we decided that the Plan's rules for coverage of the lens have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the lens (V2200) provided on March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on February 24, 2022, by an 
OON provider. 
 
You asked the Plan to pay for wound care supplies. You say that the enrollee has been treated for their wounds 
and billing separately for these supplies is appropriate. You say that you are expecting payment in full for these 
supplies as billed. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 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 wound care supplies provided on February 24, 
2022, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 21, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the rendering physician, provider, 
is a hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain 
the proper authorization form the patient's insurance company. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless preauthorized. 
 
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 subsequent nursing facility care provided on 
January 21, 2022, by an out-of-network (OON) provider.