Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve microsurgical techniques requiring an operating 
microscope (69990). 
 
You asked the Plan to pre-approve microsurgical techniques. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service 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 microsurgical techniques. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the provided records in this case do not specifically document enough detail with 
regard to the cervical arthrodesis surgery to show the medical necessity of the microsurgical/operating 
microscope component, and that the component is not unbundled from the other surgical codes which were 
submitted and approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of microsurgical techniques have not been met. Therefore, we decided that the 
Plan does not have to pre-approve microsurgical techniques requiring an operating microscope (69990).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient hospital stays provided from 
April 27, 2023, to June 1, 2023. 
 You asked the Plan to waive the copayments for the inpatient hospital stays. You say that you want the Plan to 
pay these bills. 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 $345 
copayment per day for days 1-5 of each inpatient hospital stay. Your contract with the Plan also clearly says 
that you then pay a $0 copayment per day for any additional days of the same inpatient hospital stay. 
 
You have been asked to pay a $345 copayment per day for days 1-5 of the inpatient hospital stay provided from 
April 27, 2023, to May 5, 2023. You have been asked to pay a total of $1,725 for this stay ($345 copayment per 
day x 5 days = $1,725). You have also been asked to pay a $345 copayment per day for days 1-4 of the 
inpatient hospital stay provided from May 28, 2023, to June 1, 2023. You have been asked to pay a total of 
$1,380 for this stay ($345 copayment per day x 4 days = $1,380). This item/service falls within the inpatient 
hospital care benefit category. You have not been asked to pay after day five or for the day you were 
discharged. 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 copayments for the inpatient hospital stays provided from 
April 27, 2023, to June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit for the evaluation and management 
provided on June 21, 2023. 
 
You asked the Plan to pay for a home or residence visit for the evaluation and management. You say that the 
services were medically necessary. 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 or residence visit 
for the evaluation and management provided on June 21, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on March 13, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that the facility is obligated to obtain a prior 
authorization for the services. 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 skilled nursing facility 
provided on March 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound infectious agent panel provided on June 21, 2023, 
billed with codes 87640, 87651, 87641, 87500, and 87798. 
 
You asked the Plan to pay for the wound infectious agent panel as billed . You say that this testing was 
medically necessary.  The Plan denied your request. The Plan says this was not billed correctly. Only one unit 
of 87801 is approved for payment.  
 
The Plan must follow Medicare rules. Medicare rules say that a single laboratory procedure shall be reported as 
one unit of service whether it generates one or multiple results. When multiple procedures, multiple 
methodologies, or multiple kits are medically necessary and used, additional units may be covered.   
 
We looked at the file and Medicare rules. The file shows that the pathogens were tested using the nucleic acid 
probe technique. There is no evidence that additional procedures, methodologies, or kits were used. Based on 
this information, we decided that Medicare rules for coverage of the wound infectious agent panel as billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the wound infectious agent 
panel provided on June 21, 2023, billed with codes 87640, 87651, 87641, 87500, and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring services provided on July 31, 2023. 
 
You asked the Plan to pay for the remote monitoring services. 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 the remote monitoring 
services provided on July 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on February 9, 2023, billed 
with codes 87637 and 87631. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 

The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on February 9, 2023, billed with codes 87637 and 87631.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for parking fee, a hospital fee, and a prescription payment 
provided from February 11, 2023, to May 12, 2023. 
 You asked the Plan to reimburse for a prescription . You say that you wish to appeal the denial. The Plan 
denied your request. The Plan says parking fees and outpatient prescription costs are not listed as being covered 
under the members supplemental Wallet Benefit 
 
The Plan must follow Medicare rules. Medicare rules say that the item or service must be primarily health 
related; that is, the primary purpose of the item or service is to prevent, cure or diminish an illness or injury. If 
the primary purpose of the item or service is comfort, cosmetic or daily maintenance, then it is not eligible as a 
supplemental benefit.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of parking fee, a hospital fee, and a prescription payment have not been met. Therefore, we decided 
that the Plan does not have to reimburse for parking fee, a hospital fee, and a prescription payment provided 
from February 11, 2023, to May 12, 2023.  
 
Benefits for a prescription  may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on June 16, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan. You say that you did not 
have to pay for this service in the past. 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 $195 
copayment for outpatient diagnostic tests, including CT scans. 
 
You have been asked to pay a $195 copayment for the computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests, including CT scans 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 $89.80. Therefore, we decided that the Plan does not have to waive the 
copayment for the computed tomography (CT) scan provided on June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment  includes placement 
(D6057) and abutment supported porcelain/ceramic crown (D6058) Tooth #11. 
 
You asked the Plan to pre-approve the dental services. You say that you do not agree with the denial of the 
requested services. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit was exhausted with prior authorization dates April 13, 2023, to July 12, 2023, and 
September 14, 2023, to December 13, 2023. Therefore, we decided that the Plan does not have to pre-approve a 
custom fabricated abutment  includes placement (D6057) and abutment supported porcelain/ceramic crown 
(D6058) Tooth #11.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backrest angle, adjustable with push handle (K0108). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that the enrollee is a full-time wheelchair 
user due to her Parkinson's disease. All of the accessories are medically necessary for the enrollee's condition. 
The Plan denied your request. The Plan says the adjustable backrest with push handle is only for caretaker 
convenience. It is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a backrest angle, adjustable with push handle (K0108).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the joint ultrasound provided on June 20, 
2023. 
 
You asked the Plan to waive the copayment for the joint ultrasound. You say that you do not understand how 
the Plan did not pay for 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 $110 
copayment for outpatient diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $110 copayment for the joint ultrasound. This item/service falls within the 
outpatient diagnostic tests, 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 $36.46. Therefore, we decided that the Plan does not have to waive the copayment 
for the joint ultrasound provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement the lesion removal procedure provided on 
March 13, 2023. 
 
You asked the Plan to pay for the debridement the lesion removal procedure. 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 the debridement the 
lesion removal procedure provided on March 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injection provided on June 09, 
2023. 
 
You asked the Plan to waive the coinsurance for the drug injection. You say that you have never had to pay for 
this service in the past. 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 in-network Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the drug injection. This item/service falls within the in-
network 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. The total you owe is $276.22 ($1,381.08 allowed amount x 20% 
coinsurance = $276.22). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
drug injection provided on June 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 01, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services were medically necessary. 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 office visit provided 
on May 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 9, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the service was not authorized. 
 
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 the office visit provided on January 9, 2023, by an 
OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator 
provided on March 08, 2023. 
 
You asked the Plan to waive the coinsurance for an automatic external defibrillator. You say that you were told 
that you would not owe 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for an automatic external defibrillator. This item/service falls 
within the durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The total you owe is $669.80 ($3,348.99 allowed 
amount x 20% = $669.80 rounded up). Therefore, we decided that the Plan does not have to waive the 
coinsurance for an automatic external defibrillator provided on March 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on July 03, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you should not have to pay the cost 
share applied to the claim asthe doctor asked if you had anything else to discuss then billed you for answering 
your questions. 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 $10 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an office visit provided on July 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each radiation therapy service provided on 
March 16, 2022, to March 31, 2022. 
 
You asked the Plan to waive the coinsurance for each radiation therapy service. You say that you already met 
your deductible. 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 30% 
coinsurance for out-of-network outpatient diagnostic tests and therapeutic services, including radiation therapy. 
 
You have been asked to pay 30% coinsurance for each radiation therapy service. This item/service falls within 
the out-of-network outpatient diagnostic tests and therapeutic services, including radiation therapy 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 each radiation therapy service provided on 
March 16, 2022, to March 31, 2022.