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

 
We decided that the Plan does not have to pay for an office visit provided on April 12, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say to waive the no prior authorization denial based on 
medical necessity.  The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on April 12, 2022, by 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic test on July 05, 2022. 
 
You asked the Plan to waive the copayment for diagnostic test. You say that you want to appeal the amount 
being charged. 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 $5 
copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility). Covered 
services include, but are not limited to laboratory tests. 
 
You have been asked to pay a $5 copayment for diagnostic test. This item/service 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 diagnostic test on July 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 13, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99310) provided on May 
24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were provided by an out-of-network 
provider. There was no prior authorization or referral for the services. The services were not urgent or emergent 
and could have been provided by an in-network provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care (99310) provided 
on May 24, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast. 
 
You asked the Plan to pre-approve the MRI. You say that it is reasonable to think that the right implant has 
ruptured and is leaking. The Plan denied your request. The Plan says per the expert review and testimony, there 
is no rupture and this is not indicated. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that you have had both 
mammography and right breast ultrasound showing no evidence of implant rupture. Absent any suspicion of 
implant abnormality on conventional imaging the medical necessity of MRI of the breasts has not been 
established. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the breast.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0426 billed for date of service April 4, 2022. 
 
You asked the Plan to pay for code G0426. You say that the patient was seen by providers of different 
specialties. The Plan denied your request. The Plan says payment for code G0426 is bundled into payment for 
code 99222. 
 
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 G0426 
is a column II code to column I code 99222 with a modifier indicator of 0. The column II code is therefore not 
payable. It should be noted that although you claim that providers of different specialties provided these 
services, the claims for each of these codes list the same rendering provider (not different providers.)  Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not 
have to pay for code G0426 billed for date of service April 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the intravenous immune globulin infusions 
provided from May 9, 2022, to May 31, 2022. 
 
You asked the Plan to waive the coinsurance for the intravenous immune globulin infusions. You say that you 
would like the Plan to fully cover all expenses. 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 20% 
coinsurance for Medicare part B covered chemotherapy drugs and other part B covered drugs. The total 
allowed amount was $4,197.86 with a coinsurance amount of $839.56 ($4,197.86 total amount x 20% 
coinsurance). 
 
  You have been asked to pay a $839.56 coinsurance for the intravenous immune globulin infusions. This 
item/service falls within the Medicare part B prescription drugs benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for the intravenous immune globulin infusions provided from May 9, 2022, to May 
31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (64625). 
 
You asked the Plan to pre-approve radiofrequency ablation. 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. Medicare rules say that radiofrequency ablation for denervation whether 
performed using traditional, cooled, or pulsed radiofrequency is considered investigational and therefore, not 
medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (64625).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from February 
20, 2022, to February 23, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that your records and EOB state that 
the "customer balance is $0.00". 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 $320 
copayment per day for days 1 to 5 for inpatient hospital care. You were there for two days, resulting in a $640 
total copayment ($320 x 2 days = $640). 
 
You have been asked to pay a $640 copayment for an inpatient 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 an inpatient stay provided 
from February 20, 2022, to February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram on July 20, 2022. 
 
You asked the Plan to waive the copayment for an electrocardiogram. You say that you would like to appeal 
the cost share. 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 $75 
copayment for an electrocardiogram.  
 
You have been asked to pay a $75 copayment for an electrocardiogram. This item/service 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 electrocardiogram on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an optometry visit provided on July 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an optometry visit. You say that the beneficiary needed this service, this should 
be covered. The Plan denied your request. The Plan says there was no preauthorization by a primary care 
provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 an optometry visit provided on July 7, 2022, by an 
out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management provided on  
March 23, 2022. 
 
You asked the Plan to pay for hospital discharge day management. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 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 dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital discharge day management provided on 
March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on June 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that it was medically necessary for the patient to 
receive these services, and the facility should have gotten authorization. The Plan denied your request. The 
Plan says 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 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 medical services provided on June 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the patient's doctor sent the specimen to you for 
medically necessary testing. The Plan denied your request. The Plan says unauthorized, out-of-network 
services are 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. 
 
Neither the referring provider nor the lab in this case is 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. Therefore, we decided that the Plan does not have to pay for lab services provided on August 1, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aquatic membership/services provided February 1, 2022, 
through April 30, 2022. 
 
You asked the Plan to pay for the aquatic services. You say that you swim for aerobic exercise. The Plan 
denied your request. The Plan says aquatic services are not covered under your benefits. The Plan also says that 
a one-time exception was made to pay for aquatic services in 2021 and you were informed that these services 
would not be covered in the future. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only for approved memberships or instructional fitness classes. 
 
The Plans rules for coverage of gym benefits have not been met because aquatic services are not covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the aquatic 
membership/services provided February 1, 2022, through April 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit (G0463) 
and a debridement procedure (97597) provided on June 16, 2022. 
 
You asked the Plan to waive the copayment for the outpatient visit. You say that you would like the services 
reprocessed. 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 $350 
copayment for services provided at an outpatient hospital facility. 
 
You have been asked to pay a $313.94 copayment for an outpatient visit. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
category. You are being asked to pay less than the contracted rate and therefore, you are only responsible for 
this lower amount.  
 
 
 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 hospital outpatient clinic visit (G0463) and a debridement 
procedure (97597) provided on June 16, 2022.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, basic life support, non-emergency transport 
(A0428, A0425) provided on December 24, 2021. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says that Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided proof of hospice enrollment. Therefore, 
we decided that the Plan has to pay for ambulance service, basic life support, non-emergency transport  
(A0428, A0425) provided on December 24, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for placement of drug eluting intracoronary 
stent provided on April 20, 2022. 
 
You asked the Plan to waive the copayment for placement of drug eluting intracoronary stent. You say that you 
will not pay and do not want to ruin your credit. 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 20% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. The allowed amount of this 
outpatient diagnostic test total $12,153.03, resulting in a coinsurance amount of $2,430.61. 
 
You have been asked to pay 20% coinsurance for placement of drug eluting intracoronary stent. This 
item/service 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 placement of drug eluting intracoronary stent provided on 
April 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee. 
 
You asked the Plan to pre-approve a microprocessor knee. 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 a determination of the type of knee for the prosthesis 
will be made by the treating practitioner and/or the prosthetist based upon the functional needs of the 
beneficiary. 
 
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 microprocessor knee. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found in this case, the 
documentation does not indicate why a K3 level microprocessor knee is medically necessary over a mechanical 
knee. 
 
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 microprocessor knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a microprocessor knee.