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 hospital visit provided from 
June 25, 2021, to June 29, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $400 copayment per day for days 1-4 of for Inpatient Hospital Care.  
 
 
  The enrollee has been asked to pay a $1,400 copayment for 4 days of inpatient hospital care ($400 x 4 = 
$1,400). 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 an inpatient hospital visit 
provided from June 25, 2021, to June 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 9, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 January 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on  
July 28, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each out-of-network Medicare covered primary care doctor visit.  
 
 
 You have been asked to pay a $50 copayment for the out-of-network Medicare-covered primary care doctor 
visit provided. This means that you have been asked to pay the correct amount based on your contract with the 
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for the office visit (99214) provided on July 28, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Physical Therapy provided on November 15, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Physical Therapy. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required, and it was determined 
these services were not urgent or emergent. 
 
 
 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 Physical Therapy provided on November 15, 2021 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement of the copayment for the magnetic resonance 
imaging (MRI) of the brain (70553) provided on November 12, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment after the deductible is met for each advanced imaging service.  
 
You have been asked to pay a $200 copayment for the advanced imaging service provided. This means that you 
have been asked to pay the correct amount based on your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to issue reimbursement of the copayment for the magnetic resonance 
imaging (MRI) of the brain (70553) provided on November 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) rendered on August 
28, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for these services. Our reviewer says that the 
criteria for coverage are not met. Our physician reviewer found the submitted records indicate that the 
enrollee's diabetes might be too tightly controlled. There is no specific clinical rationale for the CGM. The 
records do not show that the criteria for coverage were met and the CGM was therefore not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the continuous glucose monitor (CGM) rendered on August 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 14, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on July 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 
You asked the Plan to pre-approve Xgeva. The Plan denied your request. The Plan says the member has not 
tried and failed the preferred step therapy drugs intravenous pamidronate or zoledronic acid. 
  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 Xgeva. Our reviewer says that based on 
the medical records provided, the enrollee has not tried and failed the required drugs. Our physician reviewer 
found that there is no indication that the Plan's required drugs would likely be less effective and/or likely have 
adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram on November 26, 
2021. 
 
You asked the Plan to waive the copayment for an electrocardiogram. You say that you were unaware there 
would be a copayment. The Plan denied your request. The Plan says the copayment applied was 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 $10 
copayment for an electrocardiogram.  
 
You have been asked to pay a $10 copayment for an electrocardiogram. An electrocardiogram 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 November 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 2, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and 
there was no approved authorization, and it was determined that the services rendered were not urgent or 
emergent. Also, the services rendered 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 an office visit provided on December 2, 2021 by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on November 24, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy services. You say that you do not have an authorization because 
it was withdrawn once your claims were on file. The Plan denied your request. The Plan says the attending 
provider involved in these services is non-participating, and the referring provider is also non-participating. 
The Plan also says that they did not authorize any services for this 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 physical therapy services provided on November 
24, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the ultrasound of the abdominal aorta (76706) provided on November 
22, 2021. 
 You asked the Plan to pay for the ultrasound. You say that this service was billed correctly with a screening 
diagnosis to show medical necessity. The Plan denied your request. The Plan says that the diagnosis provided 
in this case is inconsistent with the procedure provided. 
 
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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ultrasound have been met. Specifically, the ultrasound was provided as a screening for AAA in 
an individual with a family history of AAA. The service was billed with CPT code 76706 as directed by 
Medicare guidelines. This service was billed with a screening diagnosis, and there are no Medicare criteria 
regulating what diagnosis codes must be billed for this service. Therefore, we decided that the Plan has to pay 
for the ultrasound of the abdominal aorta (76706) provided on November 22, 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 pre-approve Pantoprazole. 
 
You asked the Plan to pre-approve Pantoprazole. You say that this drug is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's 
medical 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 Pantoprazole.  
 Benefits for Pantoprazole 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on December 
12, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for Urgently needed services.  
 
 
  You have been asked to pay a $45 copayment for an urgent care visit. 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 urgent care visit provided on December 12, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve transforaminal epidural injection (TFESIs) 
 
You asked the Plan to pre-approve the TFESIs. You say that you would like reconsideration because the 
requested injection is medically necessary. The Plan denied your request. The Plan says that the medical 
necessity of the denied procedure has not been established after clinical review. 
 
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 the TFESIs. Our reviewer says that the 
documentation supports that the coverage criteria for bilateral epidural steroid injections at the L4/5 and L5/S1 
levels have been met in this case, Our physician reviewer found the request in this case is for TFESIs at two (2) 
nerve root levels during the same session. 
 
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 TFESIs have been met. Therefore, we decided that the Plan has to pre-
approve transforaminal epidural injection (TFESIs)  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services provided on June 24, 2021. 
 
You asked the Plan to pay for critical care services. The Plan denied your request. The Plan says the 
documentation submitted on appeal consists of duplicate records previously reviewed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of critical care services provided on  
June 24, 2021 have been met. Therefore, we decided that the Plan does not have to pay for critical care services 
provided on June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the dental services provided on December 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were referred to this provider and advised 
that they accepted your insurance. The Plan denied your request. The Plan says that the provider in this case is 
not contracted with the Plan; therefore, these services are denied. 
 
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, there are discrepancies throughout the case file regarding the date 
of the services at issue and the exact services that were provided. The Plan writes in the narrative and in their 
notes that the date of service for this case is January 4, 2022; however, the case was submitted with the date of 
service indicated as December 22, 2021, and the claims screen and provider documentation supports this date. 
In addition, the Plan did not provide the contract for the 2021 plan year, nor did they provide the dental benefit 
guide for the 2021 plan year. Without the contract and this documentation, we cannot verify the rules that the 
Plan cites in their denial. Therefore, we decided that the Plan has to pay for the dental services provided on 
December 22, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. The Plan denied your request. The Plan says the 
enrollee's needs can be met with a lower level of service such as Personal Care and Homemaking. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 
  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 home health aide services. Our 
reviewer says that the requested home health services are not medically necessary. Our physician reviewer 
found that you do not require additional skilled nursing services or skilled rehab services. You have been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. You need 
custodial care and supervision which can be provided by the authorized 24.5 hours a week of personal 
care/home-maker 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 home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for special anesthesia service provided on January 7, 2022. 
 
You asked the Plan to pay for special anesthesia service. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
this code is always bundled for payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that code 99100 is always bundled for payment and is 
not separately payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of special anesthesia service have not been met. Therefore, we decided that the Plan does not have to 
pay for special anesthesia service provided on January 7, 2022.