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

 
We decided that the Plan does not have to pay for laboratory testing provided on March 15, 2023. 
 
You asked the Plan to pay for laboratory testing. 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 laboratory testing 
provided on March 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on March 01, 2023. 
 
You asked the Plan to pay for laboratory testing. You say that the patient was in a facility and could not select 
their provider. You depend on the facility to get authorizations if they are needed. 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 laboratory testing 
provided on March 01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on January 23, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are requesting the submitted documentation be 
reviewed. 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 lab testing provided on 
January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the new patient office visit to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that this visit is to advance the condition of your 
health. The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
new patient office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 provided on December 7, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit.  
We find that CPT code 99223 is not supported in the medical record. Specifically, the file shows that the 
enrollee was admitted as an outpatient on the date of service at issue in this appeal. Code 99223 is an inpatient 
code. Based on this information, we decided that Medicare rules for coverage of procedure code 99223 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99223 provided on 
December 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the specialist office visit and the aflibercept 
injection provided on January 12, 2023. 
 
You asked the Plan to reduce the cost share for the specialist office visit and the injection. You say that you 
were told that you would have a $30 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 $30 
copayment for services from a specialist. Your contract with the Plan also clearly says that you must pay 5% 
coinsurance for each Medicare-covered Part B drug. 
 
You have been asked to pay a $30 copayment for the specialist 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. 
 
You have also been asked to pay $90.30, which is 5% coinsurance of the allowed amount for the injection 
($1,806 x 5% = $90.30). This item/service falls within the 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. Therefore, we decided that 
the Plan does not have to reduce the cost share for the specialist office visit and the aflibercept injection 
provided on January 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport 
provided on November 29, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
not transported to the hospital. You also say that only your blood pressure was checked at the scene. The Plan 
denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 29, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment with no 
transport provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve pain management. You say that regardless of the denial reason, no one 
consulted you and you want this decision reversed immediately. The Plan denied your request. The Plan says 
the enrollee must receive their care from a network provider. In most cases, care the enrollee receives from an 
out-of-network provider (a provider who is not part of the plans network) will not be 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
pain management to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on February 07, 
2023. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that this should be fully covered. 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 $50 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $50 copayment for the ultrasound. 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 the ultrasound provided on February 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve  an epidural steroid injection. You say that the enrollee would like 
reconsideration because the services are medically necessary. The Plan denied your request. The Plan says an 
epidural steroid injection is not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline for at least three months. 
 
  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 epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found that 
there is no documentation showing at least 50 % pain relief for 3 months. 
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LinQ sacroiliac (SI) joint stabilization system 
(0775T). 
 
You asked the Plan to pre-approve a LinQ SI joint stabilization system. You say that the enrollee's clinical 
records document that a comprehensive diagnostic workup has been performed and clearly indicates a 
diagnosis of sacroilitis. You also say that since all non-operative treatment approaches have failed to alleviate 
the pain, SI joint fusion is deemed to be medically necessary at this time in the enrollee's continuum of care. 
The Plan denied your request. The Plan says there is no medical proof that this type of joint stabilization 
system will help with lower back pain that is long-lasting. 
 
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 a LinQ SI joint stabilization system. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the detailed documentation is not evident regarding any sacroiliac joint 
pathology on the provided x-rays. There is limited published, large-scale, long-term peer-reviewed literature 
that shows this request to be an effective and/or safe treatment for the noted pathology. Our reviewer found that 
no compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of 
this request as an exception. Our physician reviewer found that therefore, the requested LinQ SI joint 
stabilization system, in this case, is not medically reasonable or 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 a LinQ SI joint stabilization system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a LinQ sacroiliac (SI) joint stabilization system (0775T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic chair (E1399). 
 
You asked the Plan to pre-approve an orthopedic chair. You say that you need an orthopedic chair so that you 
can sit up and not be laying down all the time. You also say it would assist you with getting to watch television 
and just for back pain. The Plan denied your request. The Plan says the requested item is not medical in nature 
and is regularly and primarily used by persons who do not have a specific medical need for them, and therefore 
is not covered. 
 
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 an orthopedic chair (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an ER visit and self-administered drugs provided 
from January 28, 2023, to January 29, 2023. 
 
You asked the Plan to waive the cost for an ER visit and self-administered drugs. You say that you do not have 
a secondary insurance to the current 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $382.38 copayment for an ER visit and self-administered drugs. This total 
includes a $90 copayment for an ER visit and $292.38 for self-administered drugs. The ER visit falls within the 
emergency 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. 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 waive the cost for an ER visit and self-administered drugs provided 
from January 28, 2023, to January 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for diabetic supplies provided on January 13, 
2023, and February 17, 2023. 
 
You asked the Plan to reduce the coinsurance for diabetic supplies. You say that that you should be charged a 
10% coinsurance not 20%. 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 diabetic supplier. 
 
  You have been asked to pay a total of $61.20 for diabetic supplies. The total amount allowed to be billed for 
diabetic supplies provided on January 13, 2023, was $153.01. You have been asked to pay an $30.60 
coinsurance for these services, which is 20% of the total allowed amount. The total amount allowed to be billed 
for diabetic supplies provided on February 17, 2023, was $153.01. You have been asked to pay an $30.60 
coinsurance for these services, which is 20% of the total allowed amount. The CGM and supplies falls within 
the diabetes self-management training, diabetic 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 reduce the coinsurance for diabetic supplies provided on January 13, 2023, and February 17, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on January 11, 2023, 
to January 17, 2023.  
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that similar previous bills were 
paid 100%. 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 $230 
copayment each day for days 1 to 7 for Medicare-covered hospital care each time you are admitted. $0 
copayment for additional Medicare-covered days. You pay these amounts until you reach the out-of-pocket 
maximum. Includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of 
inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a 
doctors order. The day before you are discharged is your last inpatient day. There were 6 days. 6 x $230 = 
$1,380. The member was accessed a copayment in the amount of $1,338.59 as this claim met the annual out-of-
pocket maximum. Therefore, resutls in the total cost sharing amount of $1,338.59. 
 
You have been asked to pay a $230 copayment each day for 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. Therefore, we decided that the Plan does not have to waive the copayment for 
inpatient hospital stay on January 11, 2023, to January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 17, 2023. 
 
You asked the Plan to pay for lab services. You say that you cannot afford to let these claims go unpaid. 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 lab services provided on 
January 17, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that admission to a SNF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the enrollee does not meet the Medicare criteria for 
SNF care. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 
require daily skilled nursing and/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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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.