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 
January 30, 2022, to January 31, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says the clinical findings and treatments noted do not meet any of the 
guidelines. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that in the case of this patient, the provided documentation (very limited) did not 
show that at the time of inpatient admission the admitting physician reasonably expected that the patient's 
necessary hospital care would span two midnights. There was no description provided of the patient's medical 
history, treatments or proposed treatments in the hospital setting which would support inpatient 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee from January 30, 2022, to 
January 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on 
February 08, 2022, to February 15, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you cannot afford the 
copayment. 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 $1,600 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,600 copayment for the inpatient hospital care. 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. The EOC says there is a $320 copayment per day for days 1-5 of inpatient care per 
admission. Your stay lasted 7 days. Your total for the first 5 days of care is $1,600. Therefore, we decided that 
the Plan does not have to waive the copayment for the inpatient hospital care provided on February 08, 2022, to 
February 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an ultrasound, office visit and ECG provided 
on May 25, 2022, and June 8, 2022. 
 
You asked the Plan to waive the cost share for an ultrasound, office visit and ECG. You say that the provider 
should not charge more than the insurance company will pay. 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 $10 
copayment for non-radiological diagnostic services, $100 copayment for Medicare covered radiological diagnostic services, and $30 copayment for services obtained from a specialist. 
 
You have been asked to pay a total of $80 copayment since you already paid $60 at time of visits for an 
ultrasound, office visit and ECG. This item/service falls within the Outpatient diagnostic tests and therapeutic 
services and supplies and 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 cost share for an ultrasound, office visit and ECG provided on May 25, 
2022, and June 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on March 31, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that the copayment responsibility was unclear 
to you. 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 20% 
coinsurance for Medicare-covered equipment and supplies.  
 
You have been asked to pay a coinsurance of $408.43, which is 20% of the allowed amount for DME 
($2,042.13 allowed x 20% = $408.43). This item/service falls within the Durable Medical Equipment (DME) 
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 DME 
provided on March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services, a brief emotional/behavioral assessment, 
and a hospital outpatient clinic visit provided on June 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services, a brief emotional/behavioral assessment, and a hospital 
outpatient clinic visit. You say that this was medically necessary. The Plan denied your request. The Plan says 
this provider is not a network provider with the Plan and the services were not referred by a network provider. 
The Plan also says that these services were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services, a brief emotional/behavioral 
assessment, and a hospital outpatient clinic visit provided on June 16, 2022, by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request is not medically necessary. The services you need will best be determined 
after you have been fully evaluated and treated. You may discuss this with your provider. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve imaging guidance for radiation therapy. 
 
You asked the Plan to pre-approve the requested services. You say that the service properly targets the lesion 
being treated. The Plan denied your request. The Plan says picture studies are not supported to guide the 
enrollee's type of treatment. 
 
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 requested services. Our physician 
reviewer found that using ultrasound on a daily basis is not unreasonable, but to bill for daily simple 
simulations and/or IGRT for a technology for which need has not been established by published data or 
supported by consensus guidelines. Daily simulations or IGRT would not be furnished in accordance with 
accepted standards of medical practice. 
 
 
 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve imaging guidance for radiation therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on 
April 15, 2022. 
 
You asked the Plan to waive the copayment for laboratory tests. You say that the Plan should cover everything, 
and you should not pay anything for annual routine check. 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 $10 
copayment for each Medicare-covered lab service.  
 
You have been asked to pay $10 copayment for laboratory tests. This item/service falls within the Medicare-
covered lab service 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 outpatient diagnostic 
tests provided on April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service March 5, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99053 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service March 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (CPT code J9271). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the Medicare-approved cancer drug books (compendia) and cancer journals do not 
support the use of the requested drug regimen for treatment of locally advanced anaplastic thyroid carcinoma. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found the requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. The use is not supported 
by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid 
Services (CMS)-approved medical journal . 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda (CPT code J9271).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with Auto-expiratory positive airway pressure (EPAP) (AE) that could be 
delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found the requested device is being used in the BiPAP mode rather than being used as a home 
ventilator. Products classified as Healthcare Common Procedure Coding System (HCPCS) code E0466 when 
used to provide continuous positive airway pressure (CPAP) or bi-level PAP (with or without backup rate) 
therapy, regardless of the underlying medical condition, shall not be paid in the Fee-For-Service (FSS) payment 
category.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on March 
25, 2022, to March 30, 2022. 
 
You asked the Plan to waive the copayment for hospital care. You say that you should not have copayment. 
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 $260 
copayment for inpatient hospital care per day, days 1 to 5. This inpatient hospital stay lasted 5 days, resulting in 
a copayment of $1,300 ($260 per day for 5 days = $1,300). 
 
You have been asked to pay $260 copayment per day for hospital care. This item/service falls within the days 1 
to 5 of a hospital stay 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 inpatient 
hospital care provided on March 25, 2022, to March 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a chest x-ray provided on June 16, 2021. 
 
You asked the Plan to waive the copayment for a chest x-ray. You say that this is such an old bill, you feel the 
facility should eat the 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). Your contract with the Plan clearly says that you must pay a $50 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $28.71, which is less than the original copayment of $50 for a chest x-ray. This 
item/service 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 chest x-ray provided on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laminectomy for implantation of neurostimulator 
electrodes, plate/paddle, epidural (63655), and insertion or replacement of spinal neurostimulator pulse 
generator or receiver, direct or inductive coupling (63685). 
 
You asked the Plan to pre-approve the spinal cord stimulator (SCS). You say that the enrollee was not able to 
undergo a stimulator trial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that SCS is eligible for coverage after demonstrated pain 
relief with a temporarily implanted electrode precedes permanent implantation  
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 spinal cord stimulator (SCS). Our 
reviewer says that the requested spinal cord stimulator (SCS) is not medically necessary. Our physician 
reviewer found the provided documentation did not indicate that the enrollee had a trial (temporary placement) 
of an SCS as required before receiving a permanent one. Therefore, the reviewer found that the requested SCS 
is not 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 the spinal cord stimulator (SCS) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a laminectomy for implantation of neurostimulator electrodes, 
plate/paddle, epidural (63655), and insertion or replacement of spinal neurostimulator pulse generator or 
receiver, direct or inductive coupling (63685).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the computed tomography (CT) scan of the 
abdomen and pelvis provided on June 09, 2022. 
 
You asked the Plan to waive the deductible for the computed tomography (CT) scan of the abdomen and pelvis. 
You say that you should only have to pay your $165 copayment. 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 $950 
deductible for radiological diagnostic services, not including x-rays. 
 
You have been asked to pay a $950 deductible for the computed tomography (CT) scan of the abdomen and 
pelvis. This item/service falls within the radiological diagnostic services, not including x-rays 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. Please note that the $165 
copayment was applied after the deductible was met. Therefore, we decided that the Plan does not have to waive the deductible for the computed tomography (CT) scan of the abdomen and pelvis provided on June 09, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulse oximetry procedure (A0999) provided on May 6, 
2022. 
 
You asked the Plan to pay for the pulse oximetry procedure. You say that you would like this service to be 
covered. The Plan denied your request. The Plan says this service is not reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for the pulse oximetry procedure (A0999) provided on May 6, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Radiologic examination, foot; complete, minimum of 3 
views (73630-26-LT) provided on March 17, 2022. 
 
You asked the Plan to pay for procedure code 73630-26-LT. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously 
paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 26, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 73630-26-LT have not been met. Therefore, we decided that the Plan does not have to pay for the Radiologic examination, foot; complete, 
minimum of 3 views (73630-26-LT) provided on March 17, 2022.