Persius/hicric huggingface dataset:
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 26, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that the 
copayment is a financial hardship and you did not understand that you would be responsible to pay anything. 
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 $125 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $125 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 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on February 22, 2023. 
 
You asked the Plan to pay for a home visit evaluation. You say that you are requesting reconsideration of the 
denied claim. 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 a home visit evaluation 
provided on February 22, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from November 1, 
2022, to November 16, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that you are unable to afford the cost share 
applied. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 copayment for days 1 to 20 and a $188 copayment per day for days 21 to 100 for SNF care.  
 
 
  The enrollee has been asked to pay $1,692 for SNF care ($188 per day x 9 days = $1,692). This item/service 
falls within the SNF care benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
SNF care provided from November 1, 2022, to November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for the evaluation and management provided on 
February 01, 2023. 
 
You asked the Plan to pay for home visit for the evaluation and management. You say that it is the 
responsibility of the facility to obtain prior authorization. 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 home visit for the 
evaluation and management provided on February 01, 2023.
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 March 15, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you went to 
the hospital and was billed for an MRI but feel the copayment is too high. 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 $250 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $250 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 March 15, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive urine drug testing (UDT) for 15-21 drug classes (G0482).  
 
You asked the Plan to pay for the definitive UDT for 15-21 drug classes. You say that this testing is medically 
necessary. The Plan denied your request. The Plan says that ordering a multi-class panel of definitive urine 
drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the definitive UDT for 15-21 drug classes. 
Our reviewer says that this service is medically necessary. Our physician reviewer found that the enrollee has 
chronic pain and was considered a high-risk patient. The enrollee was prescribed oxycodone and Methadone as 
well as cyclobenzaprine. Methadone and cyclobenzaprine were not detected. Definitive testing is indicated in a 
high-risk patient with inconsistent results. The testing was medically 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 definitive UDT for 15-21 drug classes have been met. Therefore, we 
decided that the Plan has to pay for the definitive urine drug testing (UDT) for 15-21 drug classes (G0482).   
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 18, 
2022, through January 22, 2023. 
 
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 medical records have not been provided 
to substantiate the medically necessity of the inpatient hospital care provided.  
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of these services have been met.    
 
 
Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from 
January 18, 2022, through January 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on February 15, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. 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 a home visit provided on 
February 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on December 17, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that the amount 
billed for the service rendered is excessive and in conflict with applicable Federal regulations. 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 $200 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $200 copayment for a computed tomography (CT) scan. 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 
computed tomography (CT) scan provided on December 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on January 10, 2023. 
 
You asked the Plan to pay for rest home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all patients. 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 rest home visit provided 
on January 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MRI provided on April 18, 2023. 
 
You asked the Plan to pay for the MRI. You say that you do not agree with the denial of payment for the MRI. 
The Plan denied your request. The Plan says there was no prior authorization for the services rendered. 
 
Medicare rules say that plans may choose the networks of providers available to enrollees and may require 
enrollees to obtain authorization before receiving services. 
 
The requested provider in this case is a network provider with the Plan. The Plan did not pre-approve the MRI 
at issue. We found no exception that would require the Plan to pay for the MRI. Therefore, we decided that the 
Plan does not have to pay for the MRI provided on April 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 7, 
2022, through August 9, 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 the acute inpatient hospital care provided was 
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 does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) on August 7, 2022 with diplopia. 
On evaluation her vital signs were stable; she was unable to adduct the left eye during the neurological exam. 
The computed tomographic angiography (CTA) demonstrated no acute process. She was admitted, the 
echocardiogram was normal and she was evaluated by speech therapy, physical therapy, and occupational 
therapy. She was discharged home on August 9, 2022 with a 30 day event monitor. An outpatient follow-up 
was arranged. The review has determined that the record did not show 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 not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from August 7, 2022, through August 9, 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 February 06, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you were 
advised by the providers office that you would not have a 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 $200 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $200 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. The total you owe is $195.33, which is less than the standard copayment for an 
MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance 
image (MRI) provided on February 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943) 
provided on March 1, 2023.  
 
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 this service is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943) provided on 
March 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 3 sensor. You say that the enrollee needs this to be able 
to check and monitor glucose levels. The Plan denied your request. The Plan says there is no indication the 
member is not able to use the preferred Freestyle Libre 2. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.   
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a FreeStyle Libre 3 sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on December 
12, 2022. 
 You asked the Plan to pay for the subsequent hospital care. You say that the physician provided medically 
necessary services to the enrollee in good faith. You also say that you feel the doctor is entitled to 
reimbursement. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 10, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care (99232) provided on December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84520, 85014, 85018, 85049, 81000, 81003, 
82040, 82247, 82248, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84295, 84450, 84460, 85027, 83721, 
84155, 86141, 82607, and 82746 billed for date of service March 1, 2021. 
 
You asked the Plan to pay for procedure codes 84520, 85014, 85018, 85049, 81000, 81003, 82040, 82247, 
82248, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84295, 84450, 84460, 85027, 83721, 84155, 86141, 
82607, and 82746. You say that you would like the Plan to reconsider their denial of payment. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for procedure codes 84520, 85014, 85018, 85049, 81000, 81003, 82040, 
82247, 82248, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84295, 84450, 84460, 85027, 83721, 84155, 
86141, 82607, and 82746 billed for date of service March 1, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 81345 provided on October 20, 2022. 
 
You asked the Plan to pay for procedure code 81345. 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 as billed. 
 
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 procedure code 81345 by a contract provider. The file does not show that the plan 
provided notice that procedure code 81345 would not be covered. Under Medicare rules, this means procedure 
code 81345 is considered approved by the plan. Therefore, we decided that the Plan has to pay for procedure 
code 81345 provided on October 20, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that you need the 
additional trips to multiple providers including pain management. The Plan denied your request. The Plan says 
you have exhausted your benefit of 24 one-way trips per year.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional routine transportation trips for appointments. Based on this information, we decided that you have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve additional routine transportation trips.