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

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from July 11, 
2022, to July 25, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you would like the inpatient stay 
to be classified as one large stay, rather than two separate smaller ones. 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 $360 
copayment per day, days 1 to 5 for inpatient hospital care. You are being charged for a total 7 days, at $360 per 
day, totaling $2,520 ($360 x 7 = $2,520). 
 
You have been asked to pay $360 copayment per day, days 1 to 5 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 July 11, 2022, to July 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that this care is medically necessary. 
The Plan denied your request. The Plan says the requested care is not medically necessary. 
 
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 if it is determined that the requested care is 
medically necessary. 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 hyperbaric oxygen therapy to be provided by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve operative resection of the rectal polyp. We decided that the Plan 
does not have to pre-approve inpatient admission.  
 
You asked the Plan to pre-approve operative resection of the rectal polyp and inpatient admission. You say that 
the services are necessary. The Plan says that medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
We decided that the Plan has to pre-approve operative resection of the rectal polyp.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 operative resection of the rectal polyp. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested operative resection of the rectal polyp above the dentate line 
is medically necessary to prevent cancerous transformation.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of operative resection of the rectal polyp have been met. 
 
Therefore, we decided that the Plan has to pre-approve operative resection of the rectal polyp.  
 
We also decided that the Plan does not have to pre-approve inpatient admission. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 inpatient admission. Our reviewer says 
that the requested items/services are considered not medically reasonable and necessary in this case. Our 
physician reviewer found the inpatient admission is not medically necessary, as this can be performed in an 
outpatient setting or observation. 
 
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 admission has not been met. 
 
Therefore, we decided that the Plan does not have to pre-approve inpatient admission. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) on February 20, 2022. 
 
You asked the Plan to pay for magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration of the denied claim. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
Based on this information, we decided that Medicare rules for coverage of magnetic resonance imaging (MRI) 
have not been met. Therefore, we decided that the Plan does not have to pay for magnetic resonance imaging 
(MRI) on February 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
15, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility care visit provided on May 23, 2022. 
 
You asked the Plan to pay for a nursing facility care visit. You say that services were rendered in good faith, as 
it is the facilitys responsibility to obtain an authorization. The Plan denied your request. The Plan says that 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility care 
visit provided on May 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endoscopy service provided on April 5, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for endoscopy service. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says there was no prior authorization obtained for the 
services provided. 
 
 
 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 endoscopy service provided on April 5, 2022, 
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 April 13, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on April 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care services provided on 
July 20, 2022, to July 25, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care services. You say that you are disputing 
the share cost. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $750 copayment for inpatient hospital care.  
 
The enrollee has been asked to pay $750 copayment for inpatient hospital care services. This item/service falls 
within the inpatient hospital care 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 
copayment for inpatient hospital care services provided on July 20, 2022, to July 25, 2022.
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 you fractured your hip while visiting your son in 
California and you believe that you are not able to fly home in the condition you are currently in.  You say that 
the services are medically necessary so that you will be able to fly back home. The Plan denied your request. 
The Plan says the services are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement. However, the documentation doesnt support that you meet criteria for 
admission to an acute inpatient rehabilitation facility. You can receive further services at a lower level 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walk-in tub provided on June 23, 2022. 
 
You asked the Plan to pay for the walk-in tub. You say that a walk-in shower became too challenging. The Plan 
denied your request. The Plan says a walk-in tub is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for a walk-in tub provided on June 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ostomy items provided from June 1, 2022, 
to June 10, 2022. 
 
You asked the Plan to waive the coinsurance for ostomy items. You say that you were not told there was a 
coinsurance for these items. 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 prosthetic devices and related supplies. The allowed amount of this drug or item is $432.06, 
resulting in a coinsurance amount of $86.39 ($432.06 x 20% = $86.39). 
 
You have been asked to pay an $86.39 coinsurance for ostomy items. This item/service falls within the 
prosthetic devices and related 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 coinsurance for 
ostomy items provided from June 1, 2022, to June 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a specialist visit. You say that you have seen several doctors with your Plan, 
and none have been able to assist with your condition. The Plan denied your request. The Plan says services 
requested are available with 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 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 specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 6, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing care provided on April 04, 2022. 
 
You asked the Plan to pay for the subsequent nursing care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the subsequent nursing 
care provided on April 04, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote patient monitoring services provided on April 25, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for remote patient monitoring. You say that the provider is the only one that can 
perform the services. The Plan denied your request. The Plan says the services must be obtained from an in-
network provider and that there is no prior authorization on file for these services. 
 
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 remote patient monitoring services provided on 
April 25, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance; cervical or thoracic, single facet joint (64633) and destruction by neurolytic 
agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each 
additional facet joint (64634). 
 
You asked the Plan to pre-approve facet joint injections. You say that the requested injections are medically 
necessary due to spondylosis without myelopathy or radiculopathy, cervical region. The Plan denied your 
request. The Plan says no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months 
for each covered spinal region. The enrollee would not be eligible for a repeat facet RFA in the same entire 
region until 03/10/23. 
 
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two 
(2) radiofrequency sessions will be reimbursed per rolling 12 months. 
 
We looked at the file and Medicare rules. The records show that the enrollee had RFA sessions performed on 
3/9/22 and 4/4/22 in the cervical region. Medicare rules say that no more than two RFA sessions will be 
reimbursed per rolling 12 months. Based on this information, we decided that Medicare rules for coverage of 
facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve 
destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance; cervical or thoracic, 
single facet joint (64633) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging 
guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (64634).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
computed tomography (CT) scan (78816). 
 
You asked the Plan to pre-approve a PET/CT scan. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a PET/CT scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the prostate-specific antigen (PSA) is 
normal, and a PET/CT scan would not be indicated at this time. 
 
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 PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan with computed tomography (CT) scan 
(78816).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve the additional non-emergency transportation. You say that you need more 
trips for the rest of this year as you need to see a couple of doctors in November and December. The Plan 
denied your request. The Plan says your benefit plan does not cover more than 40 one-way trips per plan year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 40 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.