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 July 
9, 2021, to July 14, 2021. 
 You asked the Plan to pay for the services. You say that you maintain that A41.9 remains a valid diagnosis for 
this encounter, as it was documented by the provider and meets coding guidelines for the principal diagnosis. 
The Plan denied your request. The Plan says the DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 the 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found that while it is acknowledged that the records include a physician-documented 
diagnosis of sepsis, and that Systemic Inflammatory Response Syndrome (SIRS) signs were present along with 
an elevated lactic acid, the clinical findings in the record do not sufficiently support the diagnosis of sepsis 
based on Sepsis 3 criteria. The review has determined that the records did not support that A41.9 - sepsis, 
unspecified organism - was an appropriate principal diagnosis code in this case. The records did not support the 
use of DRG 871 for this inpatient stay.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from July 9, 2021, to July 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the magnetic resonance angiography (MRA) 
and gadobutrol injection provided on January 28, 2022. 
 
You asked the Plan to waive the cost share for the MRA with contrast agent. You say that you should not be 
responsible for this copay because the denial notice has costs you time and stress. 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 $250 
copayment for diagnostic imaging and a 20% coinsurance for Part B drugs.  
 
  
You have been asked to pay $250.61 for the MRA with contrast agent ($3.04 the allowed amount for contrast 
agent x 20% coinsurance = $.61 + 250 for MRA = $250.61). The MRA falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. The gadobutrol 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 waive the cost share for the 
magnetic resonance angiography (MRA) and gadobutrol injection provided on January 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a kidney imaging morphology provided on 
December 9, 2021. 
 
You asked the Plan to waive the copayment for the kidney imaging. You say that the doctor's office informed 
you there was no record of a visit on that day. 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 day for diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay a $325 copayment for the kidney imaging. The kidney imaging 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 a kidney imaging morphology provided on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network urgent care visit provided on 
December 2, 2020. 
 
You asked the Plan to waive the copayment for an in-network urgent care visit. You say that the office never 
notified you there would be a copayment, therefore you should not have to pay this 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 $25 
copayment for urgently needed services.  
 
You have been asked to pay a $25 copayment for an in-network urgent care visit. An in-network urgent care 
visit falls within the Urgently Needed 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 an in-network urgent care visit provided on December 2, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 4, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 15, 2022, 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 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. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on April 15, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on March 23, 2021. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 $30 
copayment for out-of-network primary care physician visit. Covered services include medically-necessary 
medical care or surgery services furnished in a physicians office, certified ambulatory surgical center, hospital 
outpatient department, or any other location. 
 
You have been asked to pay a $30 copayment for office visit. Office visits fall within the Physician/Practitioner 
services, including doctor's 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 
for office visit on March 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed before coverage can be 
approved. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a trastuzumab injection provided on 
October 13, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you cannot afford the charges for 
the services. 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 chemotherapy drugs.  
 
You have been asked to pay $159.55, which is 20% of the allowed amount for the injection ($797.75 allowed amount x 20% coinsurance = $159.55). 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 waive the coinsurance for a trastuzumab injection 
provided on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on September 23, 
2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you should not have to pay this 
amount because you reached your maximus-out-of-pocket (MOOP) amount already. The Plan denied your 
request. The Plan says the copayment applied was correct - you had not yet met your MOOP at the time of this 
visit. 
 
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 physician/practitioner services, including doctor's office visits.  
 You have been asked to pay a $45 copayment for a specialist visit. a specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's 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 for a specialist visit provided on September 23, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on April 08, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 $90 
copayment for each emergency room visit in the U.S. If you are admitted to the hospital within 24 hours, you 
do not have to pay your share of the cost for emergency care. Emergency care refers to services that are: 
furnished by a provider qualified to furnish emergency services and needed to evaluate or stabilize an 
emergency medical condition. 
 
 
 
 You have been asked to pay a $90 copayment for emergency room services. Emergency room services 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 emergency 
room services on April 08, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network (OON) skilled nursing 
facility (SNF) care provided from November 17, 2021, to December 5, 2021. 
 
You asked the Plan to waive the coinsurance for the OON SNF care. You say that you are on a limited income 
and cannot afford the coinsurance. 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 30% 
coinsurance for each stay at an out-of-network facility. 
 
Dates of Service Allowed Amount 30% Coinsurance 
November 18, 2021  November 30, 2021 $9,342.90 $2,807.82 
December 1, 2021  December 5, 2021 $3,329.54 $998.86 
Total:  $3,806.68 The file shows that the Plan verified the facility is not a network facility. Therefore, you have been asked to 
pay a total of $3,806.68, which is 30% of the allowed amount for the OON SNF care. The OON SNF care falls 
within the Skilled Nursing Facility (SNF) 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 
coinsurance for out-of-network (OON) skilled nursing facility (SNF) care provided from November 17, 2021, 
to December 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network specialist visit, and an 
out-of-network wellness visit provided on May 11, 2021. 
 
 
You asked the Plan to waive the copayment for an out-of-network specialist visit and an out-of-network 
wellness visit. You say that you thought these providers were in network and therefore you should not have to 
pay these copayments. 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 $30 
copayment for an out-of-network annual physical exam, and a $60 copayment for an out-of-network 
Physician/Practitioner services.  You have been asked to pay a $30 copayment for an out-of-network wellness visit, and a $60 copayment for an 
out-of-network specialist visit ($30 + $60 = $90). An out-of-network specialist visit and an out-of-network 
wellness visit falls within the Annual Physical Exam and Physician/Practitioner 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 an out-of-network specialist visit, and an out-of-network 
wellness visit provided on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel provided to the enrollee on January 
21, 2021.  
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says testing for over 640 genes and classifiers without a targeted plan of action and a non-
verified gene panel is not medically reasonable in such a case. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the diagnosis is confirmed as adenocarcinoma. Treatment should be specific to small number of 
reasonable gene targets. Blanket gene testing is not appropriate. Over 50 gene targets is considered 
investigational per evidence based practices and the standard 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Tempus gene panel provided to the enrollee on January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5260) provided on December 6, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that your provider contacted the Plan and was advised 
of your benefit. You also say that you contacted the Plan after the hearing aids were delivered to inquire about 
reimbursement from the Plan. The Plan denied your request. The Plan says you did not use an in-network 
provider. The Plan also says that neither you nor your provider contacted the Plan between February 19, 2020, 
and February 22, 2022. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased through the Plan's approved hearing aid vendor. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5260) provided on December 6, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmological comprehensive 
medical examination provided on May 5, 2022. 
 
You asked the Plan to waive the copayment for the comprehensive eye exam. You say that this service should 
have been part of the routine eye exam. 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 $45 
copayment for vision services.  
 
This was a diagnostic service and part of a treatment program and not a routine eye exam. You have been asked 
to pay a $45 copayment for the comprehensive eye exam. The comprehensive eye exam falls within the Vision 
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 the ophthalmological 
comprehensive medical examination provided on May 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on February 7, 2022, to 
February 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic services. You say that you have previously appealed this 
enrollee's services and the denials were overturned. You say these claims should have been paid. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
 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 did not pre-approve the 
chiropractic services. We found no exception that would require the Plan to pay for the chiropractic services. 
The records provided for review do not show that the chiropractic services were urgent or emergent. Therefore, 
we decided that the Plan does not have to pay for the chiropractic services provided on February 7, 2022, to 
February 10, 2022, by an out-of-network (OON) provider.