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

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
February 10, 2022, to February 11, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says the physician's judgement about the anticipated time in the hospital 
was not keeping with the standard of care. 
 
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 pay for 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 that the patient presented to the emergency department on 2/10/22 with complaint of 
confusion and leg infection. The evaluation revealed mental status to be at his baseline and mild cellulitis of the 
leg. He was admitted for antibiotic therapy and discharged on 2/11/22. The record does not show that the 
admitting physician reasonably expects that the patients necessary hospital care will span two midnights. 
 
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 pay for inpatient hospital services provided to the enrollee from February 10, 2022, to 
February 11, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a primary care (PCP) office visit provided on March 
18, 2022. 
 
You asked the Plan to waive the copayment for the PCP visit. You say that this was an annual wellness visit 
and you should not have been charged. The Plan denied your request. The Plan says that you have been 
charged the correct cost sharing amount. 
 
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 forwarded the medical records pertaining to this 
visit. Without this documentation, we are unable to verify if other services were provided during the same visit. 
It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial is not 
substantiated, so we must find in your favor. Therefore, we decided that the Plan has to waive the copayment 
for a primary care (PCP) office visit provided on March 18, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 18, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. 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 authorization is 
required prior to 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 laboratory services provided on March 18, 2022, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 11, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were not aware that you 
would owe $30 for each visit. 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 $30 
copayment for each physical therapy visit.  
 You have been asked to pay a $30 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on March 11, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an emergency room visit provided from March 14, 
2022, to March 16, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were hospitalized 
during your emergency room stay, and per your coverage, states you would owe $0 for the emergency room. 
You would like this copayment removed. The Plan denied your request. The Plan says that the copayment 
applied was correct. 
 
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 enrollees must pay If you are admitted to the hospital within 24 hours for the 
same condition, you pay $0 for the emergency room visit. for emergency care.  
 
The Plan says you must pay a $90 copayment for an emergency room visit. Based on the Plan contract, 
however, you cannot be asked to pay if you are admitted to the hospital within 24 hours for the same condition, 
you pay $0 for the emergency room visit. Therefore, we decided that the Plan has to waive the copayment for 
an emergency room visit provided from March 14, 2022, to March 16, 2022.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy and endoscopy 
performed on April 28, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy and endoscopy. 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 a $325 
copayment per visit for surgery or services provided at an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay a $325 copayment for the colonoscopy and endoscopy. The colonoscopy and 
endoscopy fall within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers 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 diagnostic 
colonoscopy and endoscopy performed on April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient clinic visit provided on 
December 8, 2021. 
 
You asked the Plan to waive the copayment for an outpatient clinic visit. You say that you were not told by the 
provider a copayment was due at time of visit. You say that you disagree with the way the visit is being billed 
as an "outpatient hospital stay" and you were unaware of how expensive the visits were. The Plan denied your 
request. The Plan says the copayment applied is correct. 
 
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 $200 
copayment for all other outpatient services not provided in an ambulatory surgical center.  
 You have been asked to pay a $200 copayment for an outpatient clinic visit. An outpatient clinic visit falls 
within the Outpatient Surgery, including Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers, 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 outpatient clinic 
visit provided on December 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 5, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were informed there would 
be no charge for the services. 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 physical therapy visits.  
 You have been asked to pay a $20 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on March 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an outpatient procedure provided on 
March 16, 2022, April 20, 2022, and May 04, 2022. 
 
You asked the Plan to waive the copayments for an outpatient procedure. You say that you have never had to 
pay such a high copayment for this type of procedure before. The Plan denied your request. The Plan says the 
copayments applied were correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for outpatient surgery.  
 
You have been asked to pay a $835.23 copayment for an outpatient procedure ($325 + $325 + $185.23 = 
$835.23). An outpatient procedure falls within the Outpatient Surgery, Including Services Provided at 
Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 an outpatient procedure 
provided on March 16, 2022, April 20, 2022, and May 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140), 
intraoral-periapical first radiographic image (D0220), and the extraction of an erupted tooth requiring removal 
of bone and/or sectioning of tooth (D7210) provided on April 18, 2022. 
 
You asked the Plan to pay for the dental 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 dental services were received from 
an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 The record shows you received the dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided are not covered under this benefit when 
received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation-problem focused (D0140), intraoral-periapical first radiographic image (D0220), and 
the extraction of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on 
April 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 9, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were informed there would 
be no charge for the services. 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 physical therapy visits.  
 You have been asked to pay a $20 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on March 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya injections (J3245). 
 
You asked the Plan to pre-approve the Ilumya injections. You say that Ilumya is medically necessary. The Plan 
denied your request. The Plan says a trial of Stelara is required before alternatives can be considered. 
 
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 the Ilumya injections. Our reviewer 
says that Ilumya is not medically necessary. Our physician reviewer found the record shows no trial of the plan 
preferred drug or any reason it would be unsafe or ineffective for this patient. 
 
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 Ilumya injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Ilumya injections (J3245).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis. 
 
You asked the Plan to pre-approve Restasis. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Restasis is not covered under the enrollee's Medicare Part B 
benefit. 
 
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 Restasis.  
 
Benefits for Restasis 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 26, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were informed there would 
be no charge for the services. 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 physical therapy visits.  
 You have been asked to pay a $20 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on March 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 6, 2021, billed with 
codes 81225, 81226, 81227, 81230, 81240, 81241, 81249, 81291, 81335, 81355, and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that charges were billed appropriately. The 
Plan denied your request. The Plan says this genetic testing should be billed with only one code. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on October 6, 2021, billed with codes 81225, 81226, 81227, 81230, 81240, 81241, 81249, 81291, 81335, 81355, 
and 81408.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Otezla. 
 
You asked the Plan to pre-approve Otezla. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Otezla.  
 
  Benefits for Otezla 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: Favorable

 
We decided that the Plan has to waive the coinsurance for the outpatient surgical services (33285) provided on 
September 9, 2019. 
 
You asked the Plan to waive the coinsurance for the outpatient surgical services (33285). You say that you feel 
the incorrect cost share has applied and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says that the correct cost share has applied. 
 
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 enrollees must pay a $240 copayment for Outpatient Surgery.  
 
The Plan says you must pay a 20% coinsurance for the outpatient surgical services (33285). Based on the Plan 
contract, however, you cannot be asked to pay more than a $240 copayment for the outpatient surgical services 
(33285). Per Medicare guidelines, code 33285 is a surgical code and not paid under the Durable Medical 
Equipment Fee Schedule.  Therefore, we decided that the Plan has to waive the coinsurance for the outpatient 
surgical services (33285) provided on September 9, 2019.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (81455) provided on April 4, 2022. 
 
You asked the Plan to pay for the laboratory services (81455). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Unless a 
specific exception is met, laboratory claims should be reported with the date of service the specimen was 
collected. 
 
We find that the reported date of service of April 4, 2022, is supported in the medical record. Specifically, the 
records indicate that the sample was collected on March 2, 2022, during a hospital surgical procedure. The 
limited documentation provided indicates that the specimen was collected by a surgical team in a hospital 
setting. This means that an exception to the general rule for laboratory dates of service has been met. Based on 
this information, we decided that Medicare rules for coverage of the laboratory services have been met. 
Therefore, we decided that the Plan has to pay for the laboratory services (81455) provided on April 4, 2022.  
 
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.