Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost share for the myocardial perfusion imaging, 
tomographic (78452), the technetium tc-99m sestamibi, diagnostic, per study dose (A9500) and the 
regadenoson injection (J2785) provided on August 26, 2021. 
 
You asked the Plan to adjust the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
services provided. 
 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 $10 
copayment for Medicare-covered radiological diagnostic services, not including x-rays. You must pay a 5% 
coinsurance for each Medicare-covered Part B drug. Additionally, you must pay a 20% coinsurance for each 
Medicare-covered medical supply. Supplies for which an appropriate separate charge is made by providers 
(such as, chemical agents used in certain diagnostic procedures) are subject to cost-sharing as shown. 
 
You have been asked to pay $163.46. This amount includes a $10 copayment for the Medicare-covered 
radiological diagnostic service provided. This amount also includes the Plan allowed amount of $708 x 20% 
coinsurance=$141.60 for the medical supply provided. Additionally, this amount includes the Plan allowed 
amount of $237.24 x 5% coinsurance=$11.86 for the Medicare-covered Part B drug provided. 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 adjust the cost share for the myocardial perfusion imaging, tomographic (78452), the 
technetium tc-99m sestamibi, diagnostic, per study dose (A9500) and the regadenoson injection (J2785) 
provided on August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided from October 10, 2020, to October 
15, 2020, and billed with DRG (diagnosis related group) 196. 
 
You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your 
request. The Plan says the billed diagnosis codes are 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 provided with DRG 196, interstitial lung disease with major 
complications or comorbidities, and diagnosis codes J96.21, acute and chronic respiratory failure with hypoxia, 
and E46, unspecified protein-calorie malnutrition. 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 care. Our reviewer says that the billed DRG is not supported. Our physician reviewer found 
the records indicate the enrollee had normal breath sounds with no wheezing or rhonchi. He was in no acute 
distress and was well developed, alert, and oriented. There was no evidence of decrease in food or nutrient 
intake or muscle mass loss in the records.  
 
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 care provided from October 10, 2020, to October 15, 2020, and billed with DRG (diagnosis related 
group) 196.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayments for the therapeutic exercises (97110 x 2) 
provided on September 13, 2021 and September 30, 2021. 
 
You asked the Plan to adjust the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $40 
copayment for each physical or language therapy visit rendered by an in-network provider.  
 
 You have been asked to pay $73.85 ($40 + $33.85) for the physical therapy visits rendered by an in-network 
provider. This amount includes a $40 copayment for the physical therapy visit provided on September 13, 
2021. Additionally, this amount includes a $33.85 copayment for the physical therapy visit provided on 
September 30, 2021. This is the Plans allowed amount for the service provided which is less than the 
applicable copayment. 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 adjust the copayments for the therapeutic exercises  
(97110 x 2) provided on September 13, 2021 and September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 29, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on October 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) 
provider on September 30, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) provider on  
September 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that the procedure was not more complex than 
expected. 
 
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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The enrollee has 
advanced prostate cancer.  The records describe the patient as having obstructive uropathy with hydronephrosis related to 
mass/enlargement of prostate and bony metastatic disease. He presented to the hospital with stable vitals for a 
nephrostomy tube placement, pain medication, Foley catheter placement, and fluids. Post procedure there was 
no reported pain and the patient had stable vitals. Based on the provided documentation the patient appeared to 
be stable enough for treatment at a lower level of care than inpatient and there was no indication that they 
would require hospital services that would likely cross 2 midnights. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 your rehabilitation can be safely provided at a lower intensity and alternate setting 
such as in a skilled nursing facility or in-home with services. Documentation does not support the necessity for admission to an IRF. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
hip joint provided on August 2, 2021. 
 
You asked the Plan to waive the copayment for an MRI. You say that the charges are not justified. You also 
say that you feel the MRI you had is part of the overall operation you had. 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 $225 
copayment for diagnostic radiology services, including MRIs, in the outpatient department of a network 
hospital.  
 The record shows the claim has been processed correctly. You have been asked to pay a $225 copayment for an 
MRI. An MRI 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 a magnetic resonance imaging (MRI) of the hip 
joint provided on August 2, 2021.  
 
Your complaint about the MRI not being included in the operation you had is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 16, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the clinicals support medical necessity. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 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 16, 
2021, by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Therapeutic Procedure provided on April 28, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a Therapeutic Procedure. You say that a separate procedure was covered and this 
one should be too. The Plan denied your request. The Plan says the provider is out-of-network authorization 
was not obtained prior to the services being rendered. 
 
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 Therapeutic Procedure provided on April 28, 
2021 by an out-of-network (OON) provider.
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 LTACH is medically necessary. The Plan denied 
your request. The Plan says authorization denied because IRF is not medically necessary, and your needs may 
be met at a lower level of care such as skilled therapies at home or at a skilled nursing facility (SNF). 
 
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 that your medical problems are stable and there are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305, 88312, 88342) rendered by 
the out-of-network (OON) provider on November 23, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the laboratory services (88305, 88312, 88342) rendered by the out-of-network 
(OON) provider on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92004) provided on 
September 3, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you went in for a regular eye exam 
and you feel you should not be responsible for this cost. The Plan denied your request. The Plan says during the 
course of this eye exam, the medical record shows that you were diagnosed with age-related nuclear cataracts, 
bilateral. This is a medical diagnosis, which means you eye exam is covered by Medicare and is not considered 
routine. 
 
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 $35 
copayment for Medicare-covered eye exams to diagnose and treat disease and conditions of the eyes.  
 
You have been asked to pay a $35 copayment for the eye exam. During the course of this exam, it was 
discovered that the reason for your vision complaint is bilateral cataracts, which is a medical condition. 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 eye exam (92004) provided on September 
3, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the oral surgical splints and related services. 
 
You asked the Plan to pre-approve the oral surgical splints and related services. You say that the requested 
services are medically necessary. The Plan denied your request. The Plan says that the requested services are 
not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the oral surgical splints and related 
services. Our reviewer says that the documentation for TMJ splints meets the criteria for coverage of medically 
necessary and reasonable since the etiology is medical in nature.  
 
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 oral surgical splints and related services have been met. Therefore, we 
decided that the Plan has to pre-approve the oral surgical splints and related services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) 
provided on June 3, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that original Medicare is responsible for the 
payment of this claim as the member was enrolled in Hospice at the time of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) 
provided on June 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
thorax (71260) provided on November 24, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $285 
copayment for advanced imaging services.  
 
You have been asked to pay a $285 copayment for the advanced imaging service provided. 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 computed tomography (CT) scan of the 
thorax (71260) provided on November 24, 2021.