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

 
We decided that the Plan does not have to waive the cost share for Medicare Part B chemotherapy drugs, 
laboratory services, and outpatient hospital visits provided from December 28, 2022, to January 18, 2023. 
 You asked the Plan to waive the cost share for Medicare Part B chemotherapy drugs, laboratory services, and 
outpatient hospital visits. You say that you were not told that you would be charged for the copayment as a 
hospital stay and blood work as well. 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 Medicare Part B-covered chemotherapy drugs, a $50 copayment for laboratory services at an 
outpatient hospital setting, and a $195 copayment for each Medicare-covered outpatient facility visit.  
 
You have been asked to pay a total cost share of $1,743.94 for Medicare Part B chemotherapy drugs, lab 
services, and outpatient hospital visits.  
 
Date of Service Services Rendered Amount Allowed Amount per 
Contract 
Cost Share 
December 28, 2022 Lab Services $121.61 $50 copayment $50 
January 4, 2023 Outpatient Hospital Service $327.23 $195 copayment $195 
January 4, 2023 Medicare Part B 
Chemotherapy Drugs 
$208.99 20% coinsurance $41.80 
January 4, 2023 Medicare Part B 
Chemotherapy Drugs 
$313.48 20% coinsurance $62.70 
January 4, 2023 Medicare Part B 
Chemotherapy Drugs 
$2,612.35 20% coinsurance $522.47 
January 11, 2023 Outpatient Hospital Service $327.23 $195 copayment $195 
January 11, 2023 Medicare Part B 
Chemotherapy Drugs 
$208.99 20% coinsurance $41.80 
January 11, 2023 Medicare Part B 
Chemotherapy Drugs 
$313.48 20% coinsurance $62.70 
January 11, 2023 Medicare Part B 
Chemotherapy Drugs 
$2,612.35 20% coinsurance $522.47 
January 18, 2023 Lab Services $118.90 $50 copayment $50 
Total    $1,743.94 
 
 
The Medicare Part B chemotherapy drugs fall within the Medicare Part B prescription benefit category. The 
outpatient hospital visits fall within the outpatient hospital services benefit category. The laboratory services 
fall within the outpatient diagnostic test 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 cost share 
for Medicare Part B chemotherapy drugs, laboratory services, and outpatient hospital visits provided from 
December 28, 2022, to January 18, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the iodine agent provided on January 23, 
2023. 
 
You asked the Plan to reduce the coinsurance for the iodine agent. You say that you should only have a $50 
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 20% 
coinsurance for each Medicare-covered medical supply.  
 
 
 
 You have been asked to pay $592.32, which is 20% coinsurance of the allowed amount for the iodine agent 
($2,961.60 x 20% = $592.32). 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 reduce the coinsurance for the iodine 
agent provided on January 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for you to 
receive therapy services and for the medical supervision. The Plan denied your request. The Plan says you 
could receive your care at home with home health or at a skilled nursing facility.  
 
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 that you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT of the abdomen and pelvis; with contrast material 
provided on December 12, 2022. 
 
You asked the Plan to pay for CT of the abdomen and pelvis; with contrast material. You say that you are 
appealing the claim payment denial. 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 CT of the abdomen and 
pelvis; with contrast material provided on December 12, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 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 and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 26, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support 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 laboratory services 
provided on September 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total knee arthroplasty (27447). 
 
You asked the Plan to pre-approve the total knee arthroplasty. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the total knee arthroplasty. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case.  Our 
physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. Moreover, there are no follow-up 
exams to evaluate the effectiveness of the provided cortisone injection. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. No compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
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 total knee arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the total knee arthroplasty (27447).
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 63057 and 76000. We decided that the Plan does not have to pay for 
63012.  
 
You asked the Plan to pay for procedure codes 63012, 63057 and 76000 rendered on October 18, 2022. You 
say that this should be paid for. The Plan says that the records do not support the services billed. 
 
 
 
We decided that the Plan has to pay for 63057 and 76000.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT 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 for CPT 63057 and 76000. Our reviewer says that the 
procedure details cite that after the instrumentation had been placed, neural elements were again inspected, and 
further decompression was then carried out. Therefore, the records do support that CPT 63057 was rendered in 
this case. Additionally, the records support CPT 76000. The procedure details cite fluoroscopic images were 
taken to confirm the levels prior to the first spinal instrumentation was placed. And then again AP and lateral 
planes to confirm appropriate placement of the instrumentation. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
63057 and 76000.  
 
We also decided that the Plan does not have to pay for 63012. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT 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 for CPT 63012. Our reviewer says that the records do 
not support that CPT 63012 was a separate and distinct procedure from CPT 22633. The procedure details cite 
decompressive laminectomies/laminotomies with mesial facetectomies were done from T12-L5. At the L4-5 
level, a Gill-type decompression was done. This was performed in preparation for the performed fusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 63012 have not been met. Therefore, we decided that the Plan does not have to 
pay for 63012. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional non-emergency transportation trips. You say that you are very 
sick and need transportation due to having to see your specialist twice a month and your primary care physician 
every month. The Plan denied your request. The Plan says you have already met the maximum number of one-
way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional non-emergency transportation trips for medical appointments. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0100).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the diagnostic mammogram and biopsy 
provided on April 4, 2022. 
 
You asked the Plan to waive the cost share for the diagnostic mammogram and biopsy. You say that you 
should not have to pay since there was not any health issue found. 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 $750 deductible which applies to outpatient diagnostic tests and 
therapeutic services. Your contract with the Plan also says that you must pay a $20 copayment after meeting 
the deductible for basic imaging services, including diagnostic mammograms 
 You have been asked to pay $711.32 towards the deductible. The item or service you asked the Plan to waive 
the cost share 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 $750 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 diagnostic mammogram and biopsy was received on April 4, 2022.  
 
You have also been asked to pay a $20 copayment for the diagnostic mammogram. This item/service falls 
within the outpatient diagnostic tests and therapeutic services benefit category. You have been asked to pay a 
total of $731.32 ($711.32 deductible + $20 copayment = $731.32). 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 share for the diagnostic mammogram and biopsy provided on April 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation services provided on October 19, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the correct code was billed. The Plan denied 
your request. The Plan says unlisted procedures are not covered. 
 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 64999 is unlisted procedure, nervous system. We find 
that unlisted procedures and related services are not covered when provided in an ambulatory surgical center. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation services provided 
on October 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service February 14, 2023. 
 
You asked the Plan to pay for the lab services. You say that medical records were provided The Plan denied 
your request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. A review of the claim does not show that the required unique 
identifier was reported. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed 
for date of service February 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF care is medically necessary. The Plan denied 
your request. The Plan says  the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility. 
 
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 the enrollee was admitted to an acute hospital for revision of right hip arthroplasty 
that was done in March 2023. The enrollee is medically stable and does not need a physician's supervision three 
times a week in an IRF. The complexity of the enrollee's nursing, rehabilitation, and medical needs do not 
require an acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative care. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 12, 2023. 
 
You asked the Plan to pay for an office visit. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274) provided on December 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe this was not your mistake. 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 June 27, 2022. Therefore, 
we decided that the Plan does not have to pay for bitewings (D0274) provided on December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the specialist office visit provided on January 23, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to reimburse you for the outpatient service. You say that the enrollee had a credit of $10.36 
with this provider. You also say that evidence of this was provided. The Plan denied your request. The Plan 
says prior authorization was not obtained. 
 
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 reimburse you for care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care.  
The 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 reimburse you for these 
items/services. Therefore, we decided that the Plan does not have to reimburse you for the specialist office visit 
provided on January 23, 2023, by an out-of-network (OON) provider.