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

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility provided on June 
24, 2023, to June 30, 2023. 
 
You asked the Plan to waive the copayment for skilled nursing facility. You say that the copayment should be 
waived since you have been such a good client to the Plan. 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 $140 
copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $140 copayment for skilled nursing facility. This item/service falls within the 
Skilled nursing facility (SNF) 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 $140 copayment for a 7 day admission to a 
skilled nursing facility ($20x7=$140.00). Therefore, we decided that the Plan does not have to waive the 
copayment for skilled nursing facility provided on June 24, 2023, to June 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37765 for date of service February 2, 2023. 
 
You asked the Plan to pay for procedure code 37765. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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, the CPT Code Manual definition of code 37765 is stab phlebectomy of varicose veins, 1 extremity; 
10-20 stab incisions. 
 
We find that CPT code 37765 is not supported in the medical record. Specifically, the medical records do not 
include stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions. This means the validity and 
accuracy of the service billed is not provided. Based on this information, we decided that Medicare rules for coverage of procedure code 37765 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 37765 for date of service February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 10, 2023. 
 
You asked the Plan to pay for home health services. You say that the clerical staff was supposed to get the 
authorization before the patient was scheduled. As the patient was scheduled, you thought it had been done. 
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 health services 
provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the sleep study provided on June 6, 2023. 
 
You asked the Plan to waive the cost sharing for the sleep study. You say that you should not have to pay since 
you feel you were misdiagnosed. 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 diagnostic tests and 
therapeutic services. Your contract with the Plan also says that you must pay a $100 copayment after meeting 
the deductible for outpatient diagnostic tests provide at an outpatient hospital. 
 
 You have been asked to pay $500 towards the deductible. The item or service you asked the Plan to waive the 
cost sharing for falls within the outpatient diagnostic tests and therapeutic services benefit category. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies 
to outpatient diagnostic tests and therapeutic services. This cost sharing is a contractual obligation that had not 
been met at the time the sleep study was received on June 6, 2023.  
 
You have also been asked to pay a $100 copayment for the sleep study. This item/service falls within the 
outpatient diagnostic tests and therapeutic services benefit category. You have been asked to pay a total of 
$600 ($500 deductible + $100 copayment = $600). 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 cost sharing for 
the sleep study provided on June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on February 20, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 for the requested item or service was exhausted on date of service January 19, 2023, and 
February 1, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation 
(D0140) provided on February 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote patient monitoring provided on February 20, 2023. 
 
You asked the Plan to pay for remote patient monitoring. You say that this was medically necessary and should 
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 remote patient 
monitoring provided on February 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the total knee arthroplasty (27447), x-ray 
exam of the hip (73502),  x-ray exam of the knees (73562 x 2), office visit (99214), and the total hip 
arthroplasty (27130) provided from January 12, 2022, through April 19, 2022. 
 
You asked the Plan to issue reimbursement 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 services 
provided are not payable as they were rendered by a provider who has opted out of the Medicare program.  
 
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 issue reimbursement for the total knee arthroplasty 
(27447), x-ray exam of the hip (73502),  x-ray exam of the knees (73562 x 2), office visit (99214), and the total 
hip arthroplasty (27130) provided from January 12, 2022, through April 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for physical therapy provided on June 05, 
2023, to June 28, 2023. 
 
You asked the Plan to waive the coinsurance for physical therapy. You say that you were advised that you have 
met your deductible and that you were only responsible for your 10% 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 10% 
coinsurance for Physical therapy. 
 
You have been asked to pay 10% coinsurance for physical therapy. This item/service falls within the Physical 
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. At the time of service; you deductible was not met. $90.53 of the $800 deductible was met and $107.59 
of the $1700 Out-Of-Pocket maximum (OOPM) was met. You have been asked to pay a total of $595.51 for 
services. Therefore, we decided that the Plan does not have to waive the coinsurance for physical therapy 
provided on June 05, 2023, to June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided on March 07, 2023, to May 25, 2023. 
 
You asked the Plan to pay for office visits. 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 office visits provided on 
March 07, 2023, to May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ECG provided on August 01, 2023. 
 
You asked the Plan to waive the copayment for ECG. You say that you dont think you should be charged for 
this electrocardiogram (ECG). 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 $30 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $30 copayment for ECG. 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 copayment 
for ECG provided on August 01, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has a great risk of 
readmission to an acute level of care without a transitional/step down care plan. The Plan denied your request. 
The Plan says all the services that would be provided in the LTACH are already being provided in the already 
approved current acute care setting. 
 
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 that a recent hospitalization with transfer to a LTACH on October 9, 2023, was 
transferred and admitted back to the acute care hospital on October 10, 2023, for acute hypoxic respiratory failure requiring urgent intubation and mechanical ventilation. The enrollees hospital stay has been 
complicated by hypotension requiring vasopressors, multifocal aspiration pneumonia, septic shock, recurrent 
urinary tract infection (UTI), anemia requiring a transfusion of blood, hyperglycemia, severe 
hypoalbuminemia, acute kidney injury (AKI), hypomagnesemia, hyperphosphatemia and tracheostomy tube 
placement. The enrollee is requiring low dose pressors and has recently been febrile, rendering them unsafe for 
transfer to LTACH. 
 
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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 10, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the 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 an NGS 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 10, 2023, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Inflectra. 
 
You asked the Plan to pre-approve Inflectra. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Inflectra. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of Collagenous coloitis. The Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The 
elements of the coverage criteria are not satisfied. Therefore, the enrollee does not meet criteria for the 
requested drug. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Inflectra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Inflectra.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mandibular denture repair (D5511) provided on June 16, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 
mandibular denture repair (D5511) provided on June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this because 
it is causing you financial hardship. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services provided on January 
07, 2023. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you say that you dont feel 
liable. 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 $45 
copayment for urgently needed services. 
 
You have been asked to pay a $45 copayment for urgent care services. This item/service falls within the 
urgently needed 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 urgent care 
services provided on January 07, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on April 13, 2023, to April 
19, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that you are requesting to reconsider the claim 
for payment and seeking for review. 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 April 13, 2023, to April 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on July 19, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were unaware that this provider was 
no longer in -network. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for dental services provided on July 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0326U for date of service April 3, 2023. 
 
You asked the Plan to pay for procedure code 0326U. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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, the CPT Code Manual definition of code 0326U is targeted genomic sequence analysis panel, solid 
organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for sequence variants, 
gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0326U is not supported in the medical record. Specifically, the submitted medical 
records do not include an order and report for the billed date of service. The medical records submitted indicate 
a report date as March 28, 2023 and a collection date of March 24, 2023. This date discrepancy means the validity and accuracy of the claim cannot be verified. Based on this information, we decided that Medicare 
rules for coverage of procedure code 0326U have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 0326U for date of service April 3, 2023.