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

 
We decided that the Plan has to pay for inpatient hospital services provided from September 16, 2021, to 
September 21, 2021, at the diagnosis related group (DRG) billed (DRG 871). 
 
You asked the Plan to pay for the inpatient hospital services at DRG 871. You say that the appropriate DRG 
was billed. The Plan denied your request. The Plan says that they downgraded to DRG to DRG 689 because 
principal diagnosis code A41.51 and secondary diagnosis code R65.20 are not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.51 (sepsis due to 
Escherichia coli) and secondary diagnosis code R65.20 (Severe sepsis without septic shock). We asked our 
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the inpatient hospital services at DRG 871. Our reviewer 
says that principal diagnosis code A41.51 (sepsis due to Escherichia coli) and secondary diagnosis code R65.20 
(Severe sepsis without septic shock) are supported in the medical record. Our physician reviewer found the 
enrollee presented with sepsis criteria, including tachycardia, tachypnea, and leukocytosis. Two potential 
sources of infection were identified - urinary tract infection and pneumonia. The enrollee met criteria for severe 
sepsis with altered mental status and acute kidney injury indicating organ injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided from September 16, 2021, to September 21, 2021, at the diagnosis related group 
(DRG) billed (DRG 871).  
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that your mother has dementia and is 
declining fast, she requires 24 hour a day care. She has problems with urine and bowls requiring her to be 
cleaned at least twice a day sometimes more as she can lose her bowls and urine without warning. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve An office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve An office visit. You say that you want to continue with an OON provider. 
The Plan denied your request. The Plan says the provider is out-of-network and it was determined these 
services can be received in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
An office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
November 9, 2021, to November 12, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were in the ER for the 
entire stay without being moved to a different room. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing 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 $395 per 
day for days 1-5 and $0 per day after day 5 for each inpatient admission.  
 
The file shows that you were in the hospital from November 9, 2021, to November 12, 2021, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $395 per day for the first 3 days of inpatient care. The total for your stay is $1,185 ($395 copayment x 3 days = $1,185). Please note that the 
copayment is based on the level of care, and not necessarily the actual location. The inpatient care 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 care provided from November 9, 2021, to November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve A pneumatic compressor to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve A pneumatic compressor and segmental pneumatic appliance. You say that 
you would like to appeal the denial of the claim. The Plan denied your request. The Plan says the provider is 
out-of-network and it was determined these services can be received in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
A pneumatic compressor to be provided 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 a specialist telehealth visit provided on 
January 19, 2022. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you feel you were 
charged twice for the same service. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing 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 virtual specialist services.  
 You have been asked to pay a $20 copayment for the specialist telehealth visit. The specialist telehealth visit 
falls within the Physician/Practitioner Services, Including Doctor's 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 a specialist telehealth visit provided on January 19, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on December 8, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that a primary care physician referral is not 
needed per your contract and would like the claim reprocessed for payment. The Plan denied your request. The 
Plan says the rendering provider is an out-of-network provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 a specialist office visit provided on December 8, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a shoulder x-ray provided on January 13, 
2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that the x-ray was done in the doctors office, 
and you have never been billed for an x-ray in a doctors office. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing 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 $60 
copayment for in-network basic radiological services, including x-rays at an outpatient hospital.  
 
 The Plan confirmed that the doctors office is part of the hospital therefore, the x-ray is considered a hospital 
service. You have been asked to pay a $60 copayment for an x-ray. An x-ray falls within the Outpatient 
Hospital Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a shoulder x-ray 
provided on January 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Laboratory work provided on December 30, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. 
You say that you would like to request reconsideration for payment. The Plan denied your request. The Plan 
says the provider is out-of-network, and it was determined these services were not urgent or emergent. 
 
 
 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 work provided on December 30, 2021 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.  
 
Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a lumbar-sacral orthosis (back brace) 
provided on April 21, 2021. 
 
You asked the Plan to waive the coinsurance for the back brace. You say that the enrollee did not use the brace 
and should not pay for it. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 a 20% coinsurance for each prosthetic device or supply, including braces.  
 
The enrollee has been asked to pay $119.73, which is 20% of the allowed amount for the back brace ($598.64 
allowed amount x 20% coinsurance = $119.73). The back brace falls within the Prosthetic Devices and Related 
Supplies 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 coinsurance for a lumbar-sacral 
orthosis (back brace) provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on November 24, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that it was medically necessary to provide the 
enrollee with the supplies and you would like the claim to be reprocessed for payment. The Plan denied your 
request. The Plan says the rendering provider is an out-of-network provider and there was no referral from an 
in-network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 November 24, 
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 Injections provided on December 2, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Injections. You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says prior authorization is required for an out-of-network visit. 
 
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 Injections provided on December 2, 2021 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 17, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sent the specimen to 
you to process, and you would like the claim to be reprocessed for payment. The Plan denied your request. The 
Plan says the rendering and the referring providers are both out-of-network providers and there was no 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 the laboratory services provided on November 17, 
2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 11, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that 
has been documented.   
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bioimpedance spectroscopy assessment (93702). 
 
You asked the Plan to pre-approve the bioimpedance spectroscopy assessment. You say that the lab testing is 
medically necessary. The Plan denied your request. The Plan says this service is investigational and is non-
covered at this time. 
 
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 the bioimpedance spectroscopy 
assessment. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found currently available evidence on this test is limited and 
does not effectively show that it's use leads to improved outcomes overall for breast cancer patients compared 
to the standard of 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 the bioimpedance spectroscopy assessment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a bioimpedance spectroscopy assessment (93702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
November 21, 2021, to November 29, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you cannot afford the 
copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
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 $295 per 
day for days 1-4 and $0 per day after day 4 for each inpatient stay.  
 
The file shows that you were in the hospital from November 21, 2021, to November 29, 2021. Therefore, you 
have been asked to pay $295 per day for the first 4 days of inpatient care.  The total for your stay is $1,180 ($295 copayment x 4 days = $1,180). The inpatient care 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 care provided from November 21, 2021, to November 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a mental health office visit provided on 
January 24, 2022. 
 
You asked the Plan to waive the deductible for a mental health office visit. You say that when you called to 
inquire about switching insurance companies you were told all the doctor's you see were in-network. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $400 deductible which applies to an out-of-network mental health 
office visit.  
 
The record shows this claim was approved, and you have a cost sharing amount. The item or service you asked 
the Plan to waive the deductible for falls within the Outpatient Mental Health Care benefit category. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is $400 deductible which applies to 
an out-of-network mental health office visit. This cost sharing is a contractual obligation that had not been met at the time a mental health office visit was received on January 24, 2022. Therefore, we decided that the Plan 
does not have to waive the deductible for a mental health office visit provided on January 24, 2022.