Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic testing supplies provided on August 11, 2023. 
 
You asked the Plan to pay for the diabetic testing supplies. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the supplies rendered exceed the benefit limit. 
 
The Plan must follow Medicare rules. Medicare rules say that suppliers may dispense up to a ninety (90) day 
supply.  
 
We looked at the file and Medicare rules. Review of the file shows the same supply was billed on August 7, 
2023. The previous unit billed on August 7, 2023, is only four days until the next unit billed on August 11, 
2023. This exceeds the benefit limit for these supplies. Based on this information, we decided that Medicare 
rules for coverage of the diabetic testing supplies have not been met. Therefore, we decided that the Plan does 
not have to pay for the diabetic testing supplies provided on August 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
April 19, 2023, to April 26, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you are having 
difficulties paying the 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 $315 
copayment per day, for days 1-6, for each Medicare-covered inpatient hospital stay. There is a $0 copayment 
for days 7-90.  
 
You have been asked to pay $1,890, which is a $315 copayment per day for days one to six of the inpatient 
hospital stay ($315 copayment x 6 days = $1,890). You have not been charged after day six. This item/service 
falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the inpatient hospital care provided from April 19, 2023, to April 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for 
you. The Plan denied your request. The Plan says it is not safe for you to leave the hospital currently because 
your respiratory status is not stable. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you do not require services at the LTACH that are not available at the acute care 
hospital. There are no services available at the LTACH that you require that are not available at the health care 
setting being offered by the health plan. Given there are offered alternatives, LTACH is not medically 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement of nail provided on January 09, 2023. 
 
You asked the Plan to pay for debridement of nail. You say that this service is supported in the records. 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 debridement of nail 
provided on January 09, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
August 31, 2023, to September 03, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford the 
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 $395 
copayment for inpatient hospital care. 
 
You have been asked to pay a $395 copayment for the inpatient hospital stay. This item/service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. You have been asked to pay a total of $1,185 for the inpatient hospital stay ($395 
copayment x 3 days = $1,185). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on August 
31, 2023, to September 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Durable medical equipment (DME) 
provided on July 25, 2023. 
 
You asked the Plan to waive the coinsurance for Durable medical equipment (DME). You say that you disagree 
with the coinsurance. 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 16% 
coinsurance for Durable medical equipment (DME). 
 
You have been asked to pay 16% coinsurance for Durable medical equipment (DME). This item/service falls 
within the Durable medical equipment (DME) 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 Durable medical equipment (DME) provided on July 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient hospital tests provided on 
May 24, 2023. 
 
You asked the Plan to waive the coinsurance for the outpatient hospital tests. You say that the cost share is 
wrong. 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 35% 
coinsurance for Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 35% coinsurance for the outpatient hospital tests. This item/service falls within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for the outpatient hospital tests provided on May 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on April 10, 2023. 
 
You asked the Plan to pay for the drug testing. You say that this testing was 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 the drug testing 
provided on April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 02, 2023, 
to March 25, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you are requesting reconsideration 
for 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 subsequent nursing 
facility care provided on March 02, 2023, to March 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 119 units of code 01402 billed for date of service June 26, 
2023. 
 
You asked the Plan to pay for 119 units of code 01402. The Plan denied your request. The Plan says the billed 
units are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 119 units of code 01402 Our reviewer says 
that the records do not support 119 units of code 01402 in this case. Our physician reviewer found that the 
procedure documents "Anesthesia start: 1103; Anesthesia stop: 1242". The documented anesthesia time does 
not support 119 units. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 119 units of code 01402 have not been met. Therefore, we decided that the Plan 
does not have to pay for 119 units of code 01402 billed for date of service June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services described by code 78452 performed 
on date of service July 5, 2023. 
 
You asked the Plan to pay for 78452. You say that 78452 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 78452 is denied because it was not billed with the 
required modifier -26.  
 
The Plan must follow Medicare rules. Medicare rules say that carriers may not pay for the technical component 
(TC) of radiology services furnished to hospital patients. 
 
We looked at the file and Medicare rules. We confirmed that 78452 is a radiology service which has a separate 
TC and professional component (PC). The claim was billed with place of service 21, indicating that the enrollee received these radiology services in the inpatient hospital setting. We confirmed that in this case, 
78452 was not billed with modifier -26. According to Medicare rules, modifier -26 is required as the TC of a 
radiology service which has both a TC and PC cannot be paid to the physician when the enrollee receives 
services while at a hospital. Based on this information, we decided that Medicare rules for coverage of 78452 
have not been met. Therefore, we decided that the Plan does not have to pay for the radiology services 
described by code 78452 performed on date of service July 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 23, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services are not covered when provided OON. 
 
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 laboratory services provided on February 23, 
2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair ramp and delivery, set-up, and/or dispensing 
received on May 24, 2023. 
 
You asked the Plan to pay for the wheelchair ramp and delivery, set-up, and/or dispensing. You say that you 
the enrollee needed this ramp for their mental health so the enrollee could get out of the house. The Plan denied 
your request. The Plan says the item rendered is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the wheelchair ramp and delivery, set-up, and/or dispensing received on May 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial and electronic 
analysis of implanted neurostimulator pulse generator (63650, 95972). 
 
You asked the Plan to pre-approve an SCS trial and electronic analysis. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 SCS trial and electronic analysis. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no documentation of a psychological evaluation. Therefore, the 
criteria of the LCD/ NCD are not met.  the request is deemed not medically reasonable and necessary 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 an SCS trial and electronic analysis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial and electronic analysis of 
implanted neurostimulator pulse generator (63650, 95972).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient clinic services provided on 
September 07, 2023. 
 
You asked the Plan to waive the copayment for the outpatient clinic services. You say that you cannot afford 
the 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 $300 
copayment for outpatient hospital services. 
 
You have been asked to pay a $300 copayment for the outpatient clinic services. This item/service falls within 
the outpatient hospital services 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 $115.18. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient 
clinic services provided on September 07, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on July 3, 
2023. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you walked into the 
emergency room, there was no ambulance involved and you want this to be removed from the bill. 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 $265 
copayment for ambulance services. The record shows you received transportation services provided directly by 
your provider. 
 You have been asked to pay a $265 copayment for an ambulance ride. This item/service falls within the 
ambulance services 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 ambulance ride 
provided on July 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on August 01, 
2023. 
 
You asked the Plan to pay for chronic care management services. You say that this service is supported in the 
records. 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 chronic care 
management services provided on August 01, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve immunization administration provided on September 30, 2022. 
 
You asked the Plan to pre-approve immunization administration. You say that you are submitting the needed 
documentation. The Plan denied your request. The Plan says that the Fiscal Intermediary Rate letter was not 
submitted to determine the appropriate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that Indian Health Service (IHS) providers are paid 
for administration of vaccines based on the Medicare Physician Fee Schedule.  
 
We looked at the file and Medicare rules. The services billed on this claim are vaccine administration services. 
Therefore, payment for this claim is based on the Medicare Physician Fee Schedule and the Plan does not 
require other payment information to process the claim. The Plan did not provide any other evidence or 
rationale to support payment of the claim. Based on this information, we decided that Medicare rules for 
coverage of immunization administration have been met. Therefore, we decided that the Plan has to pre-
approve immunization administration provided on September 30, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided on 
September 19, 2022, to September 29, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the cost share is 
wrong. 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 $295 
copayment for inpatient hospital services. 
 
You have been asked to pay a $295 copayment for the inpatient hospital services. This item/service falls within 
the inpatient hospital services 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. your total copay is $2,065.00 ($295.00 x 7 days). You were not charged for days 8-10 of 
your hospital stay. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient 
hospital services provided on September 19, 2022, to September 29, 2022.