Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cystoscopy with ureteral catheterization 
(52005), closure of a fistula between the bladder and wall of the vagina (57320), six office visits (99213, 
99214), an x-ray of the chest (71046), and a cystography (x-ray) of the bladder (74430). 
 
You asked the Plan to waive the copayment for gynecologic surgery, office visits, and x-rays. You say that you 
believe these services are related to the hysterectomy you received on January 20, 2021. During this surgery, 
you say the surgeon nicked your bladder and you have been having troubles with your bladder ever since. You 
say you have had to constantly wear diapers as a result. You do not think you should be responsible to pay 
these claims because of a doctor's mistake. The Plan denied your request. The Plan says the services at issue are 
separate services and are not inclusive to the hysterectomy. Therefore, the cost-share was applied 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 $10 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits. The contract also clearly says 
that you must pay a $40 copayment for each Medicare-covered x-ray and a $250 copayment for Outpatient 
Hospital Services. 
 
You have been asked to pay a total of $620 in copayments for gynecologic surgery, office visits, and x-rays (2 
surgeries at $250 each + 2 x-rays at $40 each + 6 office visits at $10 each = $640). Gynecologic surgery and x-
rays fall within the Outpatient Hospital Services benefit category. Office visits fall within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. Since your copayment of 
$620 is less than the contractually required $640 copayment, you are only responsible for the lesser amount.  
 
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 cystoscopy with ureteral catheterization (52005), closure 
of a fistula between the bladder and wall of the vagina (57320), six office visits (99213, 99214, an x-ray of the 
chest (71046), and a cystography (x-ray) of the bladder (74430) provided from March 17, 2021, to June 17, 
2021.
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 this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for seizures. Medical problems are stable. There are no complex nursing or rehabilitation needs. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that this 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on July 16, 2021. 
  You asked the Plan to pay for the refraction. You say that you have type 2 diabetes and have been going there 
for eye exams every year. You say that you don't understand why the eye refraction was not covered. The Plan 
denied your request. The Plan says eye refractions are only covered by your plan if performed by a 
participating provider and performed as a routine screening. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when it is performed during a routine exam from a routine vision care 
provider. 
 
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 refraction have not been met. Specifically, the refraction was not performed with a routine 
exam. Therefore, we decided that the Plan does not have to pay for the refraction provided on July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 4), localized delivery of 
antimicrobial agents (D4381 x 3), and take-home drugs (D9630 x 2) provided on February 18, 2021. 
 
You asked the Plan to pay for the gingival irrigation, localized delivery of antimicrobial agents, and take-home 
drugs. You say that you were advised prior to receiving the services that your portion was $579. You say that 
you received a bill for $879. You also say that you should not be charged for something that had been approved. The Plan denied your request. The Plan says the gingival irrigation, localized delivery of 
antimicrobial agents, and take-home drugs are not listed as covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the gingival irrigation, localized 
delivery of antimicrobial agents, and take-home drugs are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921 x 4), localized 
delivery of antimicrobial agents (D4381 x 3), and take-home drugs (D9630 x 2) provided on February 18, 
2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda, Ondansetron, and Ondansetron HCL. 
 
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the continued use of this medication is not supported by compendia utilized by 
Medicare or in literature approved by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drugs. Our reviewer says that the 
requested drugs are medically reasonable and necessary. Our physician reviewer found that patients on 
maintenance pembrolizumab with oligometastatic disease can continue therapy with treatment of the 
oligometastatic disease. This is planned for this enrollee with otherwise stable disease. The use of these drugs is 
reasonable and 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 drugs have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda, Ondansetron, and Ondansetron HCL.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on April 20, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says due to the enrollee's hospice election at the time of service, this claim must be submitted 
to Original Medicare first. 
 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 medical services provided to the enrollee on April 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bioventus OsteoAMP Allograft for anterior cervical 
discectomy and fusion for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health 
problem. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested allograft is experimental in spine surgery. More research is needed. 
 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 pre-approve Bioventus OsteoAMP Allograft for anterior cervical discectomy and fusion for the 
enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for a nuclear medicine study of the heart 
muscle at rest and/or with stress and single-photon emission computed tomography (SPECT) (78452) provided 
on June 16, 2021. 
 
You asked the Plan to reduce the copayment for the diagnostic radiology service. You say that you did not 
know you would be charged $250. You believed you only had a $40 copayment for all services on your plan. 
You say you are supposed to be told how much a medical procedure is going to cost ahead of time so you can 
choose whether or not to proceed with the procedure. The Plan denied your request. The Plan says the cost-
share was applied correctly for the service at issue. Medicare-covered diagnostic radiology services that are not 
ultrasounds have a $250 copayment according to the EOC. 
 
 
 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 Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $250 copayment for the diagnostic radiology service. Diagnostic radiology 
services fall 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 reduce the copayment for a nuclear medicine study of the heart muscle at rest and/or 
with stress and single-photon emission computed tomography (SPECT) (78452) provided on June 16, 2021.  
 
Your complaint about unclear copayment terms is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. The Plan states this grievance has been filed. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve genicular RFA. You say that this procedure gave the enrollee great relief for 
over a year the last time it was done. The Plan denied your request. The Plan says the denial of authorization 
for this service is correct, because studies have not shown that this procedure is helpful for the enrollee's 
condition. 
 
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 genicular RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/investigational procedure and is the subject of ongoing 
clinical trials. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for catheter supplies you received from an 
out-of-network provider on June 10, 2021. 
 
You asked the Plan to waive the coinsurance for the out-of-network catheter supplies. You say that you believe 
this provider is overcharging for these catheter supplies. The Plan denied your request. The Plan says you were 
charged this coinsurance 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 durable medical equipment and supplies from an out-of-network provider.  
 Plans are required to pay out-of-network providers the Medicare-allowed rate for items and services.  We 
confirmed that the Medicare-allowed rate for the items you received is $1717.20 (270 catheters x $6.36). You 
have been asked to pay 20% coinsurance (which equals $343.44) for the out-of-network catheter supplies.  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 catheter supplies you received from an out-of-network 
provider on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services provided to the enrollee on May 14, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. 
 
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 asked our coder 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 Medicare billing criteria are not met. Our reviewer found the office visit 
notes do not indicate time spent, and therefore this procedure cannot be verified, as CPT 99213 is considered a 
times code for 20-29 minutes. Medicare billing criteria are not met.  
 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for physician services provided to the enrollee on May 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on June 7, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the medical records do not contain documentation of definitive laboratory results for 22 or more 
drug classes, including metabolites to support the coding criteria for G0483. 
 
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 Healthcare Common Procedure Coding System (HCPCS) 
G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." 
 
We asked our coder 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 reviewer found the laboratory report does not support 
22 or more drug classes documented. In this case, 18 classes were documented. There is a more appropriate 
code to report for the services provided. 
 
We looked at this coder'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 drug testing services provided to the enrollee on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a tooth extraction provided by an out-of-network provider on 
March 3, 2021, to March 24, 2021. 
 
You asked the Plan to pay for a tooth extraction. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says this provider has opted out of Medicare; therefore, these services have been 
correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 

 The rendering dentist has opted-ed out of Medicare from July 13, 2017, to July 23, 2023. Therefore, we 
decided that the Plan does not have to pay for a tooth extraction provided by an out-of-network on  
March 3, 2021, to March 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) services (70481) provided 
on July 1, 2021. 
 
You asked the Plan to pay for the CT services. You say that you would like this claim reprocessed based on the 
medical records. The Plan denied your request. The Plan says an appropriate modifier was not billed as 
required by Medicare rules. 
 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 70481 
is a column II code to column I code 70450. 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 the computed tomography (CT) services (70481) provided on 
July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular testing provided on February 2, 2021 billed with 9 
units of code 88374. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes.  
 We asked our coder 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 Medicare billing 
criteria are not met. Our reviewer found the documentation indicates that the enrollee has a history of anemia, 
thrombocytopenia and intermittent monocytosis. The Provider submitted the claim with 2 lines for 88374, one 
with 5 units and the other line with 4 units. Per the Medicare guidelines the claim can only be filed with 5 units 
maximum. The Plan has allowed the maximum units to be paid. The documentation did not support the 4 units 
billed in excess were provided and medically necessary. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for molecular testing provided on February 2, 2021 billed with 9 units of code 88374.