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

 
We decided that the Plan does not have to pay for inpatient hospital stay provided on December 29, 2022. 
 
You asked the Plan to pay for inpatient hospital stay. You say that you are requesting the submitted 
documentation be reviewed. 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 inpatient hospital stay 
provided on December 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial maxillary and mandibular denture (D5213 and 
D5214), provided on November 9, 2022. 
 
You asked the Plan to pay for a partial maxillary and mandibular denture. You say that you would like the Plan 
to pay for this. The Plan denied your request. The Plan says these dentures have been correctly denied. 
 
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. The Plan covers a partial 
maxillary and mandibular denture when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a partial maxillary and mandibular denture have not been met. Therefore, we decided that the Plan does not have to pay for a partial maxillary and mandibular denture (D5213 and D5214), provided on 
November 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on November 18, 
2022, to November 23, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you believe you may have 
been billed twice. 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 per day, days 1 to 5. $0 copayment per day, days 6 to 90 for inpatient hospital stay. Includes 
inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. 
Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor's order. The day 
before you are discharged is your last inpatient day. $325 x 5 = $1,625. Therefore, results in the total cost 
sharing amount of $1,625.  
 
You have been asked to pay a $325 copayment per day for inpatient hospital stay. 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 inpatient 
hospital stay on November 18, 2022, to November 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transesophageal echocardiography (TEE). 
 
You asked the Plan to pre-approve a TEE. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that transesophageal echocardiography (TEE) is 
ultrasonic examination of the heart performed by placing the transducer in the esophagus which allows 
different views of the heart than transthoracic echocardiography (TTE). TEE is particularly useful for posterior 
structures, such as the pulmonary veins, left atrium, and mitral valve and provides better visualization of the 
aortic root, valve and the ascending and descending aorta and arch. 
 
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 TEE. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee does not have any cardiac 
history (previously documented Valvular or congenital heart abnormalities) or symptoms. There are no clinical 
indications for this invasive test and the enrollee does not benefit from it. 
 
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 TEE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transesophageal echocardiography (TEE).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on December 06, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration and are requesting 
the claim be reconsidered for payment. 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 
December 06, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on October 19, 2022. 
 
You asked the Plan to pay for the panel testing. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel testing have not been met. Specifically, the service at issue is a test panel which was unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the panel testing provided on October 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
December 15, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the ambulance 
transportation was unnecessary. 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 ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance transportation. This item/service falls within 
the ambulance 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 the 
ambulance transportation provided on December 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on December 21, 
2022, to December 30, 2022. 
 
You asked the Plan to pay for an office visit and related services. You say that this is supported in the records. 
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 and 
related services provided on December 21, 2022, to December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network IV therapy treatment 
provided on December 15, 2022, and December 22, 2022. 
 
You asked the Plan to waive the copayment for an in-network IV therapy treatment. You say that you should 
not have any of these extra charges, when you have the same treatment in the same place, on the same day. 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 facilities, and a 20% coinsurance for Medicare Part B drugs.  
The allowed amount of this drug is $803.98, resulting in a coinsurance amount of $160.79 ($803.98 x 20% = 
$160.79). You have an outpatient facility copayment of $250 + $160.79 = $410.79 x 2 = $821.58. You have been asked to pay a total amount of $821.58 for an in-network IV therapy treatment. This 
item/service falls within the outpatient facilities and Medicare Part B drug 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 in-network IV therapy treatment provided on December 15, 2022, 
and December 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
10, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service September 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on December 29, 
2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that it is the responsibility of the facility 
to obtain authorization. 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 domiciliary or rest home 
visit provided on December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the specialist office visit provided on 
September 26, 2022. 
 
You asked the Plan to waive the deductible for the specialist office visit. You say that this service should be 
fully covered. 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 $750 deductible which applies to physician/practitioner services, 
including doctors office visits.  
 
You have been asked to pay $95 towards your deductible for the specialist office visit. The item or service you 
asked the Plan to waive the deductible for falls within the physician/practitioner services, including doctors 
office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to physician/practitioner services, including doctors office visits. This 
cost sharing is a contractual obligation that had not been met at the time the specialist office visit was received 
on September 26, 2022. Therefore, we decided that the Plan does not have to waive the deductible for the 
specialist office visit provided on September 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from September 1, 
2022, to September 15, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that the facility did not do their job in 
caring for the enrollee and the office staff was unprofessional. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 copayment for days 1 to 20 and a $188 copayment for days 21 to 100 for SNF care.  
 
 
  The enrollee has been asked to pay $752 copayment for a SNF stay ($188 per day x 4 days = $752). This 
item/service falls within the SNF 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 a SNF stay provided from September 1, 2022, to September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 18, 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 November 18, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on 
September 19, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that it is the responsibility of the 
facility to obtain authorization. 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 subsequent nursing 
facility care visits provided on September 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard liquid. 
 
You asked the Plan to pre-approve Gammagard liquid. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met.  
The Plan follows Medicare rules. Medicare rules say that intravenous immune globulin (Sandoglobulin, 
Venoglobulin-I, Privigen, Gamunex, Octagam, Gammagard liquid, Flebogamma/Flebogamma DIF, Carimune, 
Gammaplex, Bivigam) provides immediate antibody levels. 
 
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 Gammagard liquid. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee does not have adequate 
documentation to support the diagnosis of stiff man syndrome and there are no new chart notes with updated 
clinical information on this appeal. The review has determined that the enrollee does not meet the coverage 
criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gammagard liquid have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Gammagard liquid.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on March 09, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting the submitted documentation be 
reviewed. 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 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on November 11, 2021. 
 
You asked the Plan to pay for wound care. You say that you were not able to verify eligibility and obtain 
authorization. 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 wound care provided on 
November 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on June 10, 2022, billed with code 
71271. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the charges do not meet coding standards. 
 
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 imaging services provided have 
been met. Specifically, the provider has not provided medical records for the service that was billed. Therefore, 
we decided that the Plan does not have to pay for imaging services provided on June 10, 2022, billed with code 
71271.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on December 14, 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 
December 14, 2022.