Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgery services provided on January 28, 2022. 
 
You asked the Plan to pay for the assistant services. You say that this was the only available assistant at the 
time of the procedure. The Plan denied your request. The Plan says this provider is not eligible to be paid for 
this service. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgery services 
provided on January 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on October 
17, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you didn't need an 
ambulance and someone else called for you. 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 $175 
copayment for Medicare-covered one-way ground ambulance benefit.  
 
You have been asked to pay $175 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance 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 ambulance transport 
provided on October 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee will get better sooner 
at this level of care. The Plan denied your request. The Plan says the denial of authorization for acute inpatient 
hospital level of care is correct. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient level of care are met in this 
case. Our physician reviewer found the enrollee was admitted for signs of a stroke and was found to have dehydration along with kidney injuries, bladder infection, lung infection, and swallowing difficulty. The 
enrollee underwent surgery and was treated with antibiotics. There is no clinical indication for continued 
inpatient hospital services at another facility. 
 
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 pre-approve acute inpatient hospital level of care.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on February 
11, 2020. 
 
You asked the Plan to pay for the evaluation and management service. You say that payment should not have 
been recouped. You also say that the plan should not have waited this long to do so. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 2, 2020. The services in question were provided 
before the end of that month. Additionally, the record shows that the enrollee re-enrolled in hospice on 
February 12, 2020. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care 
(99232) provided on February 11, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing visits provided on January 18, 2022, to 
February 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that the claim should be reviewed and 
reconsidered for payment. The Plan denied your request. The Plan says authorization was not obtained before 
the services were rendered to the enrollee. 
 
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 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 skilled nursing visits provided on January 18, 2022, to 
February 8, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the supplies are necessary. The Plan 
denied your request. The Plan says the supplies are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on November 30, 2021. 
 
You asked the Plan to waive the copayment for ER visit. You say that you were told this would be covered. 
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 $75 
copayment for Medicare-covered emergency room visits.  
 
You have been asked to pay $72.10 copayment which is less than the standard copayment for ER visit. ER 
visits fall within the Emergency 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 
ER visit provided on November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment the office visit provided on December 28, 
2021. 
 
You asked the Plan to waive the copayment the office visit. You say that you dont understand why you get 
charged for some services and not for others. The Plan denied your request. The Plan says the copayment was 
applied 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 $10 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physician's assistant or other non-physician health care professionals in a specialists office (as 
permitted under Medicare rules).  
 
You have been asked to pay $10 for the office visit. The office visit falls within the Physician/Practitioner 
Services, Including Doctors Office Visits benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
the office visit provided on December 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy performed on March 9, 2022. 
 
You asked the Plan to waive the copayment for an endoscopy performed on March 9, 2022. You say that an 
endoscopy is categorized as a diagnostic test and should not be subject to a copayment. The Plan denied your 
request. The Plan says you are responsible to pay a $350 copayment for an endoscopy. 
 
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 Outpatient Hospital Services.  
 
You have been asked to pay a $350 copayment for an endoscopy. An endoscopy falls within the Outpatient 
Hospital Services benefit category and is considered a surgical service. 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 endoscopy performed on March 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic digital breast tomosynthesis coded 77062 
provided on August 20, 2021. 
 
You asked the Plan to pay for the diagnostic digital breast tomosynthesis. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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, the CPT Code Manual definition of code 77062 is diagnostic digital breast tomosynthesis; 
bilateral. 
 
 
 We find that CPT code 77062 is not supported in the medical record. Specifically, this code has a status code of 
"I". This means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, 
and payment of these services. Based on this information, we decided that Medicare rules for coverage of the 
diagnostic digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to 
pay for the diagnostic digital breast tomosynthesis coded 77062 provided on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. You asked the Plan to pre-approve the requested services. You say that the enrollee is in pain. The Plan denied 
your request. The Plan says the request does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The medical records show that the enrollee received an epidural 
steroid injection on June 16, 2022. A repeat injection when there has been a sustained improvement of pain for 
at least three months. Based on this information, we decided that Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for microsurgical techniques (69990) provided on January 20, 
2022. 
 
You asked the Plan to pay for microsurgical techniques (69990). You say that medical records demonstrate the 
executed services were medically necessary. You say that the claim should be reviewed and reprocessed for 
payment. The Plan denied your request. The Plan says procedure codes 63056 and 63267 have been paid. The 
Plan also says procedure code 69990 is mutually exclusive to 63267. 
 
  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 69990 
is a column II code to column I code 63267 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for microsurgical techniques (69990) provided on January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G6 receiver. 
 
You asked the Plan to pre-approve the receiver. You say that the receiver is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation does not show the enrollee is using insulin 
injections three or more times per day or that they use a Medicare-covered insulin pump. Based on this 
information, we decided that Medicare rules for coverage of the receiver have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Dexcom G6 receiver.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for psychotherapy visit on September 20, 
2021. 
 
You asked the Plan to waive the copayment for psychotherapy visit. You say that you should have been 
reimbursed more. The Plan denied your request. The Plan says the cost-sharing you are being charged is 
correct. The Plan also says that they have paid an additional $10 towards this claim, so you are only responsible 
for $20 instead of the $30 you were originally charged.  
 
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 Specialists Office, Outpatient Hospital and Partial Hospitalization. Covered services include: 
Mental health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social 
worker, clinical nurse specialist, nurse practitioner, physician assistant, or other Medicare-qualified mental 
health care professional as allowed under applicable state laws. 
 
  
You have been asked to pay a $20 copayment for psychotherapy visit. Psychotherapy visits fall within the 
Outpatient mental health 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 
psychotherapy visit on September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded81194, 81301, and 81455 
provided on December 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81194, 81301, and 81455 are not supported in the medical record. Specifically, when a 
laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part 
of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the entire 
panel. Review of the file does not support that only one code was billed for the panel. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded81194, 81301, and 
81455 provided on December 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that records show the enrollee does not have a condition which 
requires continued inpatient hospital care with daily doctor visits for more than 25 days. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. All medically necessary care is being provided in the current acute care setting. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) 
services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ECG provided on January 11, 2022. 
 
You asked the Plan to waive the copayment for the ECG. You say that you had your yearly physical exam, and 
you were charged a $10 copayment for an electrocardiogram. You say that this has never happened previously, 
and you are appealing this charge. The Plan denied your request. The Plan says the copayment applied 
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 $10 
copayment for diagnostic procedures and tests at an in-network PCPs office. 
  You have been asked to pay a $10 copayment for the ECG. The ECG falls within the "Outpatient diagnostic 
tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a 
separate service. 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 ECG provided on January 
11, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the laser-eye surgery provided on October 19, 2021. 
 
You asked the Plan to pay for the laser-eye surgery. You say that a call was made to the Plan prior to the laser 
surgery, and you were advised it would be covered in full. The Plan denied your request. The Plan says that 
your plan excludes coverage for personal comfort and convenience items. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the laser-eye surgery by a contract provider. The file does not show that the Plan 
provided notice that the laser-eye surgery would not be covered, nor were call records provided showing you 
were informed by the Plan that the service would not be covered. Under Medicare rules, this means the laser-
eye surgery is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless 
for the laser-eye surgery provided on October 19, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a Humalog injection provided on March 
25, 2022. 
 
You asked the Plan to reduce the coinsurance for the injection. You say that you have not paid more than $100 
out of pocket for the medication in the past. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay $756.52, which is 20% of the allowed amount for the injection ($3,782.62 allowed 
amount x 20% coinsurance = $756.52). The injection 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 reduce the coinsurance for a Humalog injection provided 
on March 25, 2022.