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

We decided that the Plan does not have to pay for the ultrasound scan of abdominal aorta (76706) provided on 
July 30, 2021. 
 
You asked the Plan to pay for the ultrasound scan of abdominal aorta. You say that you believe this service 
should be covered under your benefit. The Plan denied your request. The Plan says you have exhausted this 
benefit. 
 
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 $0 
copayment once per lifetime for abdominal aortic aneurysm screening.  
 
Review of the file shows that you were provided an abdominal aortic aneurysm screening on July 30, 2021.  
The records also show that you had a covered abdominal aortic aneurysm screening on July 24, 2015. This  
service is only covered once per lifetime. This means that the requested screening is your second, which  
exceeds the benefit limit. This means that you have been asked to pay the correct amount based on your  
contract with the Plan. Therefore, we decided that the Plan does not have to pay for the ultrasound scan of 
abdominal aorta (76706) provided on July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug administration services and laboratory testing provided 
on March 9, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for drug administration and lab tests. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because this provider is out-of-network with the Plan and authorization was not 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 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 drug administration services and laboratory testing 
provided on March 9, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99140, 99100) provided March 10, 
2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the codes billed 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 99140 and 99100 are not supported in the medical record. Specifically, per the 
National Physician Fee Schedule, these codes have a status of "B" which means payment is bundled with 
another service. Based on this information, we decided that Medicare rules for coverage of the anesthesia 
services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services 
(99140, 99100) provided March 10, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visit you had with a heart and vascular specialist on May 3, 2021, and the duplex scan you had on July 6, 2021.
You asked the Plan to waive the copayments for the specialist visit and the duplex scan. You say that in November of 2020, you were given a report of a significant blockage in your right leg. You said this report turned out to be false, and it caused you a lot of stress and money. You are requesting your copayments back. The Plan denied your request. The Plan says you were charged these copayments 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 $95 copayment for diagnostic procedures and tests and a $45 copayment for visits with a specialist.
You have been asked to pay a $45 copayment for the specialist visit and a $95 copayment for the duplex scan. The duplex scan falls within the diagnostic procedures and tests benefit category. These copayments apply regardless of the reason for the services. 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 office visit you had with a heart and vascular specialist on May 3, 2021, and the duplex scan you had on July 6, 2021.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. 
 
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental healthcare provided 
from May 18, 2018, to June 10, 2021. 
 
You asked the Plan to waive the copayments for outpatient mental healthcare. You say that you feel that your 
copayments are in violation of the law and you should not owe anything more than a primary care provider 
copayment. The Plan denied your request. The Plan says the claims were processed correctly, and you are 
being charged the correct 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 $20 
copayment for outpatient mental health care provided in 2018 - 2020, and a $30 copayment for outpatient 
mental health care provided in 2021.  
 
You received outpatient mental healthcare from May 18, 2018, to April 17, 2020, for a total of 5 visits. 
Therefore, you are responsible to pay a $20 copayment per each visit. The total amount you owe for these dates 
of service is: $20 (copayment) x 5 (outpatient mental health) = $100.  
 
You received outpatient mental healthcare on June 10, 2021. Therefore, you are responsible to pay the $30 
copayment.  
 
The total amount you owe is: $130.  
 
You have been asked to pay the total copayment amount of $130 for outpatient mental healthcare. Outpatient 
mental healthcare falls within the outpatient mental health 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 copayments for outpatient mental healthcare provided from May 18, 2018, to June 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) procedure you had at an ambulatory surgery center on June 3, 2021.
You asked the Plan to waive the copayment for the EGD procedure. You say that you are very high risk for Barret's esophagus because you have a swallowing defect. You said that you are at risk for future obstructions, so this is preventative for you. You stated that you have never had to pay a copayment for this before. The Plan denied your request. The Plan says you were charged this copayment 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 $275 copayment for outpatient surgery in an ambulatory surgery center. You have been asked to pay a $275 copayment for the EGD procedure. The EGD procedure falls within the
outpatient surgery in an ambulatory surgery center benefit category. This copayment applies regardless of the reason for the procedure. 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 esophagogastroduodenoscopy (EGD) procedure you had at an ambulatory surgery center on June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80053, 80061, 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81401, 82175, 82300, 82306, 82495, 82533, 82607, 82627, 82670, 82728, 82746, 82977, 83036, 83090, 83615, 83655, 83825, 84144, 84202, 84270, 84403, 84436, 84439, 84443, 84480, 84481, 84550, 85025, 86141, 86328, 87486, 87581, 87631, & 87798) provided July 14, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 80053, 80061, 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81401, 82175, 82300, 82306, 82495, 82533, 82607, 82627, 82670, 82728, 82746, 82977, 83036, 83090, 83615, 83655, 83825, 84144, 84202, 84270, 84403, 84436, 84439, 84443, 84480, 84481, 84550, 85025, 86141, 86328, 87486, 87581, 87631, & 87798 are not supported in the medical record. Specifically, the place of service listed on the claim (81, lab) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80053, 80061, 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81401, 82175, 82300, 82306, 82495, 82533, 82607, 82627, 82670, 82728, 82746, 82977, 83036, 83090, 83615, 83655, 83825, 84144, 84202, 84270, 84403, 84436, 84439, 84443, 84480, 84481, 84550, 85025, 86141, 86328, 87486, 87581, 87631, & 87798) provided July 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the walking boot you received on April 14, 2021.
You asked the Plan to waive the coinsurance for the walking boot. You say that you were told your insurance would pay for this boot. You stated that you cannot wear it because it causes discomfort and it is not the item you needed. The Plan denied your request. The Plan says you were charged this coinsurance 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 durable medical equipment. You have been asked to pay 20% coinsurance for the walking boot. The walking boot falls within the durable medical equipment benefit category. This copayment applies regardless of whether or not the item works for you. 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 walking boot you received on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76942) provided June 4, 2021.
You asked the Plan to pay for the ultrasound. You say that the 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. Providers must report services with the appropriate CPT code. We find that CPT code 76942 is not supported in the medical record. Specifically, the claim was billed with an outpatient place of service (22), however the record shows the enrollee was an inpatient at the time the service was rendered. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76942) provided June 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drug, zoledronic acid.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 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 Prolia. Our reviewer says that Prolia is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drug. The reviewer also found that there is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Specifically, the file does not show that the enrollee has tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 8, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you thought that the ultrasound 
would be included in the mammogram. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct 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 for ultrasounds.  
 
You have been asked to pay the allowed amount of $93.93, which is less than the $100 copayment for an 
ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound provided on July 
8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 18, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. 
 
Therefore, we decided that the Plan does not have to pay for the office visit provided on May 18, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 4, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you do not like to misuse your insurance. You say 
your primary care physician would only refer you to a podiatrist. 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on June 4, 2021, by an out-of-network 
(OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal cord stimulator trial. 
 
You asked the Plan to pre-approve spinal cord stimulator trial. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are only covered for certain 
indications. 
 
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 spinal cord stimulator trial. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has chronic low back and hip pain. The enrollee has tried 
physical therapy, sacroiliac joint injection, epidural steroid injection, and trigger point injection. The enrollee 
takes Hydrocodone/Acetaminophen for pain. There is no psychological evaluation, no evidence of a multi-
disciplinary consultations or an evidence-based indication for this procedure. Therefore, the enrollee does not 
meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve spinal cord stimulator trial.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested admission is 
medically necessary. The Plan denied your request. The Plan says the requested admission does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  

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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the admission was for an elective non-emergent incision and drainage 
procedure. Vitals are stable. There was no expectation that the patient would require inpatient hospital services 
related to this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on June 2, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab tests. You say that this claim was processed incorrectly. The Plan denied 
your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-
network with the Plan and the ordering provider is also out-of-network with the Plan.  
 
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 laboratory services provided on June 2, 2021 by 
an out-of-network (OON) provider.