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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 the documentation does not support the necessity for admission to an IRF. Your rehabilitation needs can be met safely at a lower intensity and alternate setting such as in a skilled nursing 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87486, 87581, 87631) provided August 18, 
2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the member's face-to-face service was rendered in a laboratory setting. 
Therefore, we decided that the Plan does not have to pay for lab services (87486, 87581, 87631) provided 
August 18, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on May 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services is considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on May 27, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies (99072) provided October 28, 2021. 
 
You asked the Plan to pay for the additional supplies. You say that the items billed were medically necessary 
due to the public health emergency. The Plan denied your request. The Plan says this code is 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 99072 is additional supplies, materials, and clinical staff 
time over and above those usually included in an office visit or other non-facility service(s), when performed 
during a Public Health Emergency. 
 
We find that CPT code 99072 is not supported in the medical record. Specifically, this code has a status of "B" 
and payment is always bundled with another service. Based on this information, we decided that Medicare rules for coverage of the additional supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for additional supplies (99072) provided October 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered 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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services provided on January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies (99072) provided February 25, 2021 to 
February 26, 2021. 
 
You asked the Plan to pay for the additional supplies. You say that the additional supplies were medically 
necessary due to a public health emergency. The Plan denied your request. The Plan says payment for this item 
is always bundled with payment for another service. 
 
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 99072 is additional supplies, materials, and clinical staff 
time 
over and above those usually included in an office visit or other non-facility service(s), when performed during 
a Public Health Emergency. 
 
We find that CPT code 99072 is not supported in the medical record. Specifically, this code has a status of "B" and payment is always bundled. Based on this information, we decided that Medicare rules for coverage of the 
additional supplies have not been met. Therefore, we decided that the Plan does not have to pay for additional 
supplies (99072) provided February 25, 2021 to February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463) provided on 
November 23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that you regularly comply with all 
administrative requirements for payments. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan and the services were not authorized by network primary care providers. The 
Plan also says that they have also determined that these services are not urgent or emergent, nor were they 
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 a hospital outpatient clinic visit (G0463) provided 
on November 23, 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 diagnostic mammography, including 
computer-aided detection (CAD) when performed; bilateral (77066) and the diagnostic digital breast 
tomosynthesis, unilateral or bilateral (G0279) provided on December 9, 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 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 $75 
copayment for diagnostic mammography services provided at an outpatient hospital.   
 
 You have been asked to pay a $75 copayment for diagnostic mammography services provided at an outpatient 
hospital. 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 diagnostic mammography, including 
computer-aided detection (CAD) when performed; bilateral (77066) and the diagnostic digital breast 
tomosynthesis, unilateral or bilateral (G0279) provided on December 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
November 27, 2021, through November 30, 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 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 $295 
copayment per admission for each medically necessary inpatient stay.  
 
You have been asked to pay a $295 copayment for the inpatient hospital admission 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 inpatient hospital care provided from 
November 27, 2021, through November 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Part B drug injections provided from 
October 8, 2021, to October 22, 2021. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you thought you only had to pay 
the copay, and nobody told you that you needed to pay for the medication. The Plan denied your request. The 
Plan says the cost share 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 a 20% 
coinsurance for each Medicare-covered Part B drug and a $30 copayment for the specialty provider's service 
for medical care or surgery services in a Specialty Physician's office. The allowed amounts of these drugs total 
$409.77, resulting in a total coinsurance amount of $81.96. There were also three visits, resulting in a total 
copayment amount of $90. Therefore, your total cost-sharing amount is $171.96. 
 
You have been asked to pay a 20% coinsurance for the Medicare-covered Part B drug and a $30 copayment for 
the specialty provider's service for the injection. The injections fall 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 the Part B drug injections 
provided from October 8, 2021, to October 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that Gel-One is medically necessary. The Plan denied 
your request. The Plan says a trial of  Euflexxa, Durolane, Supartz-FX, or Gelsyn-3 is required before 
alternative viscosupplements can be considered. 
 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 Gel-One. Our reviewer says that Gel-
One is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred 
drugs or any reason they would be unsafe or ineffective for this 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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463) provided on 
November 22, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that you regularly comply with all 
administrative requirements for payments. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan. The Plan also says that they have also determined that these services are not 
urgent or emergent, nor were they 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 a hospital outpatient clinic visit (G0463) provided 
on November 22, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drug injection (J3490) rendered by the out-
of-network (OON) provider on June 23, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the unclassified drug injection (J3490) rendered by the out-of-network (OON) 
provider on June 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
April 12, 2021, to April 27, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the cost should be 
waived due to your COVID-19 diagnosis. 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 $290 per 
day for days 1-7 and $0 per day after day 7 for each inpatient admission.  
 
The file shows that you were in the hospital from April 12, 2021, to April 27, 2021. The file also shows no 
evidence that the Plan had any cost-share waivers in effect for COVID-19 diagnoses. Therefore, you have been asked to pay $290 per day for the first 7 days of inpatient hospital services. The total for your stay is $2,030 
($290 copayment x 7 days = $2,030). The inpatient hospital services fall within the Inpatient Hospital Care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services 
provided from April 12, 2021, to April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology services (81479) provided on 
September 5, 2021. 
 
You asked the Plan to pay for molecular pathology services. You say that the services at issue are not billed 
with codes on the Physician Fee Schedule and thus not subject to the requirement to be billed with the place of 
service where the specimen is drawn. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a POS code is generally used to reflect the actual 
setting where the enrollee receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of molecular pathology services have not been met. Specifically, this claim was billed with the laboratory place of service code while the records indicate that the enrollees face-to-face service was rendered 
in an office setting. There is a more appropriate place of service code for the services billed. Therefore, we 
decided that the Plan does not have to pay for molecular pathology services (81479) provided on September 5, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgical procedure provided 
on November 4, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgical procedure. You say that the services 
should be covered as it was an injection. 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 $300 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 You have been asked to pay a $276.23 copayment for an outpatient surgical procedure, which is less than the 
standard $300. 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 outpatient surgical procedure provided 
on November 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for inpatient hospital stay 
provided between February 3, 2021 to February 8, 2021 (4 days). 
 
You asked the Plan to waive the deductible and copayment for inpatient hospital stay. You say that you were 
told that you are not responsible for the bill. The Plan denied your request. The Plan says the deductible and 
copayment amount 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 $490 
copayment each Medicare-covered day for days 1-3; $0 copayment for each additional day, after you meet your 
$395 deductible for inpatient hospital stay.  
 You have been asked to pay $1,853.60. You have been asked to pay a deductible amount of $383.60, because 
this amount met the $395 total deductible for 2021. This hospital stay lasted 4 days, resulting in a copayment 
amount of $1,470 ($490 x 3, for the first 3 days; $0 x 1, for the 4th day = $1,470). Therefore, you have been 
asked to pay a total cost-sharing amount of $1,853.60 for your inpatient hospital stay. Inpatient hospital stay 
falls within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the deductible 
and copayment for inpatient hospital stay provided between February 3, 2021 to February 8, 2021 (4 days).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for pacemaker testing provided on October 8, 
2021. 
 
You asked the Plan to waive the copayment for pacemaker testing. You say the copayment should be waived 
because you have never been charged in the past. The Plan denied your request. The Plan says the copayment 
amount 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 $20 
copayment per visit for laboratory tests, non-radiological diagnostic tests, flat film X-rays, and ultrasounds. 
 
You have been asked to pay $20 for pacemaker testing. Pacemaker testing 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 pacemaker testing provided on October 8, 2021.