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

 
We decided that the Plan does not have to waive the copayments for each inpatient hospital stay, and nuclear 
medicine heart study provided from June 27, 2022, to November 28, 2022. 
 You asked the Plan to waive the copayments for each inpatient hospital stay and nuclear medicine heart study. 
You say that you cannot afford these copayments. 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 $350 
copayment for each inpatient hospital stay. Your contract with the Plan also clearly says that you must pay a 
$150 copayment for outpatient diagnostic radiology services. 
 
You have been asked to pay a $350 copayment for the inpatient hospital stay provided from June 27, 2022, to 
July 11, 2022. You have also been asked to pay a $350 copayment for the inpatient hospital stay provided from 
August 8, 2022, to August 17, 2022. This item/service falls within the inpatient hospital care benefit category. 
You have also been asked to pay a $150 copayment for the nuclear medicine heart study. This item/service falls 
within the outpatient diagnostic tests and therapeutic 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 copayments for each inpatient hospital stay, and nuclear medicine heart study provided from June 
27, 2022, to November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology provided on January 10, 2023. 
 
You asked the Plan to pay for surgical pathology. You say that this service was billed correctly. The Plan 
denied your request. The Plan says the claim did not include the pathologist's taxonomy code as required by 
Medicare billing rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers submitting claims for their primary 
facility and its subparts must report a taxonomy code on their claims.  
 
We looked at the file and Medicare rules. The rendering providers taxonomy code was not reported on this 
claim. Based on this information, we decided that Medicare rules for coverage of surgical pathology have not 
been met. Therefore, we decided that the Plan does not have to pay for surgical pathology provided on January 
10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
February 27, 2023, to March 11, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with 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 $265 
copayment per day for days 1-6 and a $0 copayment per day for days 7-90 for inpatient hospital care.  
 
You have been asked to pay a $265 copayment per day for days 1-6 and a $0 copayment per day for days 7-90 
for inpatient hospital care. The total amount you are being asked to pay is $1,590 ($265 x 6 days = $1,590). 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 inpatient hospital care provided on February 27, 2023, to March 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab code 87640-XU provided on December 5, 2022. 
 You asked the Plan to pay for 87640-XU. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says code 87640 is included in code 87641 and use of modifier -XU is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 87640 is a column II code to column I code 87641; however, 87640 
was billed with a modifier.  
 
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 87640-XU. Our reviewer says that this code does not meet 
criteria for separate payment. Our reviewer found this code was appended with modifier -XU indicating an 
unusual non-overlapping service; however, the laboratory report does not include documentation to support this 
modifier. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87640-XU have not been met. Therefore, we decided that the Plan does not 
have to pay for lab code 87640-XU provided on December 5, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request meets our prior authorization and step therapy criteria for coverage of Xgeva 
(denosumab 120 mg/1.7 ml). As a result, our physician reviewer denied Prolia, but approved Xgeva. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the review has determined that Prolia is not 
being prescribed for a medically accepted indication. Xgeva & Prolia are not interchangeable products. 
However, the request meets the prior authorization and step therapy criteria for coverage of Xgeva (denosumab 
120 mg/1.7 ml). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft (D7953) and tissue regeneration 
(D4266) provided on April 17, 2023. 
 
You asked the Plan to pay for bone replacement graft and tissue regeneration. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for bone 
replacement graft (D7953) and tissue regeneration (D4266) provided on April 17, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee requires a short-term say at a skilled 
nursing facility to get the medical attention they need while they family gets the enrollee arranged at a long-
term care facility. The Plan denied your request. The Plan says a SNF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient surgery provided on March 1, 
2023. 
 
You asked the Plan to waive the cost share for outpatient surgery. You say that you disagree with the cost share 
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. Your 
contract with the Plan says that there is a $500 deductible which applies to outpatient surgery/ambulatory 
surgical center.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient 
surgery/ambulatory surgical center benefit category. You are being asked to pay $178.20 towards your $500 
deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible which applies to outpatient surgery/ambulatory surgical center. This cost sharing is a contractual 
obligation that had not been met at the time outpatient surgery was received on March 1, 2023. Therefore, we 
decided that the Plan does not have to waive the cost share for outpatient surgery provided on March 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on April 3, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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 pneumatic compression device provided on April 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a provider that has opted of 
Medicare. 
 
You asked the Plan to pre-approve the physician service. You say that you feel your quality of life will improve 
once you have this surgery. The Plan denied your request. The Plan says services performed by a provider that 
has opted out of Medicare are not covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pre-approve an 
office visit with a provider that has opted of Medicare.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on April 25, 2023. 
 
You asked the Plan to pay for physical therapy. You say that you trust the therapist, so you hope the visit will 
be covered. 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 physical therapy 
provided on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network prime care office visit 
provided on March 09, 2023. 
 
You asked the Plan to waive the copayment for an in-network prime care office visit. You say that this was an 
annual and should 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 $10 
copayment for each covered visit or consultation in an outpatient location with your PCP OR other primary 
care provider.  
You have been asked to pay a $10 copayment for an in-network prime care office visit. This item/service falls 
within the each covered visit or consultation in an outpatient location with your PCP OR other primary care 
provider 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 in-network prime care 
office visit provided on March 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on March 30, 2023. 
 
You asked the Plan to pay for home visit. You say that you are requesting reconsideration for the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home visit provided on 
March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for parenteral nutrition supplements B4193 provided from 
March 3, 2023, to March 8, 2023. 
 
You asked the Plan to pay for B4193. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says the claim does not include the National Drug Code number so this code cannot be 
verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code B4193 is parenteral nutrition solution; compounded 
amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any 
strength, 52 to 73 grams of protein  premix. 
 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 B4193. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found the National Drug Code (NDC) number was not documented on the 
claim; therefore, the Plan's denial is appropriate. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of B4193 have not been met. Therefore, we decided that the Plan does not have to 
pay for parenteral nutrition supplements B4193 provided from March 3, 2023, to March 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
September 17, 2022, through October 6, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on September 17, 2022, through October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on January 3, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the nursing facility care. 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 nursing facility care provided on January 3, 
2023, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute 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 this is not medically necessary. 
 
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 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on May 21, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were given the medication in the 
emergency room. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
received on May 21, 2023.  
 
Benefits for the self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an inpatient hospital stay provided from 
March 3, 2023, to March 5, 2023. 
 
You asked the Plan to reduce the copayment for an inpatient hospital stay. You say that 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 $350 
copayment per day, for days 1 to 5 and $0 copayment after day 5 of an inpatient hospital stay. 
 
 
 You have been asked to pay a $350 copayment per day, for days 1 to 2 of the inpatient hospital stay. You have 
been asked to pay a total of $700 ($350 copayment x 2 days = $700). 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 reduce the copayment for an inpatient 
hospital stay provided from March 3, 2023, to March 5, 2023.