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

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 22, 2022, 
through September 24, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the services provided were not medically 
necessary. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee was recently in the hospital for an acute ST-elevation myocardial infarction (STEMI) 
and was discharged to a skilled nursing facility. She was then discharged home with home health but returned 
to the emergency department (ED) on September 19, 2022 with worsening fatigue and generalized weakness. 
The workup showed no acute findings except a positive urinalysis for which she was started on Rocephin 
medication. The physical therapy evaluation showed no acute needs either. The enrollee requested to be held 
for an Ophthalmology evaluation and a Neurology consultation for memory issues. The review has determined 
that the record showed that at the time of the inpatient admission, the admitting physician reasonably expected 
that the enrollees necessary hospital care (including earlier ED and/or observation care) would span two 
midnights. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from September 22, 2022, through September 24, 2022.   
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 waive the coinsurance for the radiology medical supplies provided 
on October 11, 2022. 
 
You asked the Plan to waive the coinsurance for the radiology medical supplies. You say that you were told 
this was a coding mistake. 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 outpatient diagnostic tests, including medical supplies. 
 
You have been asked to pay 20% coinsurance for the radiology medical supplies. This item/service falls within 
the outpatient diagnostic tests, including medical 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. The total you owe is $208.09 ($1,040.46 allowed 
amount x 20% coinsurance = $208.09). Therefore, we decided that the Plan does not have to waive the 
coinsurance for the radiology medical supplies provided on October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 29, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you do not think that there 
should be a copayment for this visit. 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 each covered visit or consultation in an outpatient location with a specialist. 
 
You have been asked to pay a $50 copayment for a specialist visit. This item/service falls within the each covered visit or consultation in an outpatient location with a specialist 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 November 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman G3-R MIS fusion plate. 
 
You asked the Plan to pre-approve a Minuteman G3-R MIS fusion plate. You say that the requested 
Minuteman G3-R MIS fusion plate is medically necessary. The Plan denied your request. The Plan says the 
requested Minuteman G3-R MIS fusion plate is not medically necessary. 
 
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 a Minuteman G3-R MIS fusion plate. 
Our reviewer says that the requested Minuteman G3-R MIS fusion plate is not medically necessary. Our 
physician reviewer found current evidence-based medical guidelines and peer-reviewed literature do not fully 
support the interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of 
large-volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical condition. According to the Food and Drug Administration (FDA), The HA Minuteman G3-R MIS 
Fusion Plate is a posterior, non-pedicle supplemental fixation device, intended for use at a single level in the 
non-cervical spine (T1-S1). The HA Minuteman G3-R MIS Fusion Plate is intended for use with bone graft 
material and is not intended for stand-alone use. In addition, fusion indications within guidelines/literature for 
(existing or potential intraoperative) instability have not been documented and/or met in this case. In addition, 
there are multiple alternate pain generators plausibly significantly contributing to the clinical condition that has 
not been fully documented as having been excluded and/or ruled out. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested Minuteman G3-R MIS fusion plate, in this case, is not medically reasonable or 
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 a Minuteman G3-R MIS fusion plate have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Minuteman G3-R MIS fusion plate.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the requested implantable loop 
recorder is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for an implantable loop recorder. 
 
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 an implantable loop recorder. Our 
reviewer says that the enrollee does not meet criteria for an implantable loop recorder. Our physician reviewer 
found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke, or 
any other apparent indication for an implantable loop recorder. In summary, there is insufficient documentation 
to support the medical necessity for insertion of an implantable loop recorder in this enrollees clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on December 
01, 2022. 
 
You asked the Plan to waive the copayment for a breast ultrasound. You say that you do not agree with the 
copayment applied to this service. 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 $40 
copayment for outpatient diagnostic tests, including x-rays and ultrasounds. 
 
You have been asked to pay a $40 copayment for a breast ultrasound. This item/service falls within the 
outpatient diagnostic tests, including x-rays and ultrasounds 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 breast ultrasound provided on December 01, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each physical therapy (PT) visit at an 
outpatient hospital provided on November 17, 2022, to November 30, 2022. 
 
You asked the Plan to reduce the copayment for each physical therapy (PT) visit at an outpatient hospital. You 
say that you were told the copayment for PT services would be $15 per visit. 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 $40 
copayment for outpatient rehabilitation service. 
 
You have been asked to pay a $40 copayment for each physical therapy (PT) visit at an outpatient hospital. 
This item/service falls within the outpatient rehabilitation 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 reduce the copayment for each physical therapy (PT) visit at an outpatient hospital provided on November 
17, 2022, to November 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an arm and leg artery ultrasound provided 
on September 22, 2022. 
 
You asked the Plan to waive the copayment for an arm and leg artery ultrasound. You say that you do not think 
you should be responsible for this 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 $120 
copayment for in-network radiological diagnostic services, including ultrasounds. 
 
You have been asked to pay a $120 copayment for an arm and leg artery ultrasound. This item/service falls 
within the in-network radiological diagnostic services, including ultrasounds 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. However, since the allowed amount is 
less than the standard copayment, you only owe $109.66. Therefore, we decided that the Plan does not have to 
waive the copayment for an arm and leg artery ultrasound provided on September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 transforaminal epidural steroid injections (TFESIs). 
 
You asked the Plan to pre-approve TFESIs. You say that not treating all sites at once would not give the 
enrollee optimal pain control. The Plan denied your request. The Plan says the requested injections are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that it is not considered medically reasonable and 
necessary to perform multiple blocks during the same session as epidural steroid injections. 
 
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 TFESIs. Our reviewer says that the 
requested TFESIs are not medically necessary. Our physician reviewer found Medicare guidelines indicate that 
a sacroiliac (SI) joint block and TFESI are not coverable when performed within the same session. Therefore, 
the reviewer found that the TFESI cannot be approved at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TFESIs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve 2 transforaminal epidural steroid injections (TFESIs).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on December 15, 2022. 
 
You asked the Plan to pay for telehealth services. You say that it is the responsibility of the facility to obtain 
referrals. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for telehealth services 
provided on December 15, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for the emergency room visit provided 
on June 28, 2022. 
 
You asked the Plan to increase the reimbursement for the emergency room visit. You say that you were 
reimbursed the incorrect amount. The Plan denied your request. The Plan says you were reimbursed the correct 
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 $120 
copayment for emergency care.  
 
According to the EOC, the Plan will reimburse you up to 100% of Medicare's allowed amount for emergency 
services outside the United States, minus any cost sharing amount. You have been asked to pay a $120 
copayment for the emergency services. The total allowed amount is $309.05, and you were reimbursed $189.05 
($309.05 allowed amount - $120 copayment = $189.05). This item/service falls within the emergency care 
benefit category. This means that you have been reimbursed 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 increase the reimbursement for the emergency room visit provided on 
June 28, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Covid-19 testing provided on June 4, 2021. 
 
You asked the Plan to pay for Covid-19 testing. You say that the services billed were not related to hospice but 
were Covid-19 related. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for Covid-19 testing provided on June 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a polymerase chain reaction (PCR) respiratory panel (87496, 
87498, 87502, 87532, 87541, 87581, 87640, 87651, 87798, 87486) provided on September 16, 2022. 
 
You asked the Plan to pay for a PCR respiratory panel. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing was not billed with a single panel code as required.  
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a PCR respiratory panel have not been met. Therefore, we decided that the Plan does not have to 
pay for a polymerase chain reaction (PCR) respiratory panel (87496, 87498, 87502, 87532, 87541, 87581, 
87640, 87651, 87798, 87486) provided on September 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each carpal tunnel surgery provided on 
November 14, 2022, to December 05, 2022. 
 
You asked the Plan to reduce the copayment for each carpal tunnel surgery. You say that you thought you 
would be billed a $175 copayment for each surgery. 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 $275 
copayment for in-network outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $275 copayment for each carpal tunnel surgery. This item/service falls within the in-network outpatient surgery, including services provided at hospital outpatient facilities 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 total amount you owe 
is $550 ($275 copayment x 2 visits = $550). Therefore, we decided that the Plan does not have to reduce the 
copayment for each carpal tunnel surgery provided on November 14, 2022, to December 05, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 63047-59 billed for November 11, 2022. 
 
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 procedure code 63047 is not supported. 
 
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 63047 is laminectomy, facetectomy and foraminotomy 
(unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or 
lateral recess stenosis]), single vertebral segment; lumbar.  
We find that CPT code 63047 is not supported in the medical record. Specifically, there is no documentation of 
a laminectomy, facetectomy, and foraminotomy for a single lumbar vertebral segment. 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 procedure code 63047-59 billed for November 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on October 14, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that the hospital 
billing department informed you the $100 charge was a donation but you did not make a donation. 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 $100 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $100 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 
magnetic resonance image (MRI) provided on October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on December 06, 
2022. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an outpatient mental 
health visit provided on December 06, 2022.