Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
December 31, 2022, to January 19, 2023. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you would like the 
maximum out-of-pocket amount to be applied to the Plan year for 2023. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copay per day, for days 1 to 6 for each Medicare-covered admission to an inpatient hospital. 
 
The record shows you had not met your maximum out-of-pocket amount prior to this service. You have been 
asked to pay a $295 copayment per day, for days 1 to 6 of the inpatient hospital stay. The total amount you owe 
is $1,770 ($295 copayment x 6 days = $1,770). You have not been charged for any additional days. 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 an inpatient hospital stay provided from December 31, 2022, to January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on April 14, 2023. 
 
You asked the Plan to pay for a home visit. You say that the services rendered were 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 a home visit provided on 
April 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on April 
07, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were in the hospital 
during this visit. 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 $25 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $25 copayment for the specialist office visit. This item/service falls within the 
specialist physician/practitioner 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. The records show you were under observation, and the office visit 
copayment was correctly applied. Therefore, we decided that the Plan does not have to waive the copayment 
for the specialist office visit provided on April 07, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 15853 provided on 1-13070694536. 
 
You asked the Plan to pay for procedure code 15853. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code 15853 is not supported in the medical record. Specifically, this service has a 
professional component / technical component indicator of 5. The place of service billed is Emergency Room 
(23). This service is considered incident to another service and is not separately payable. Based on this 
information, we decided that Medicare rules for coverage of procedure code 15853 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 15853 provided on 1-
13070694536.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve nine months continued use of a noninvasive ventilator (E0466). 
 
You asked the Plan to pre-approve continued use of a ventilator. You say that it is necessary for the Plan to 
reconsider this denial as approved based on the facts.  The Plan denied your request. The Plan says that under 
Medicare, the request for 9 months of the NIV rental (months 4 - 12 of this request) is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 continued use of a ventilator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) and 
chronic respiratory failure and has been on Trilogy ventilator since at least 2020, with adequate treatment and 
response.  The standard of care would be to continue the enrollee's current therapy and not step down to 
BIPAP, hence, best practice.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a ventilator have been met. Therefore, we decided that the Plan 
has to pre-approve nine months continued use of a noninvasive ventilator (E0466).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on May 
01, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you did not expect 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for a 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. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit provided on May 01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx test (81551, 88387) provided on March 27, 
2023. 
 
You asked the Plan to pay for the ConfirmMDx test. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says under Medicare guidelines, your request is not medically necessary 
because your records do not show that you were being considered for a repeat biopsy. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ConfirmMDx test. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that the request was not medically 
necessary because the records did not show that you were being considered for a repeat biopsy. They did not 
show that you underwent a repeat prostate specific antigen and/or digital rectal examination after the previous 
biopsy as recommended by consensus guidelines. The review has determined that you do not meet the LCD 
criteria for coverage. 
 
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 ConfirmMDx test have not been met. Therefore, we decided that the Plan 
does not have to pay for the ConfirmMDx test (81551, 88387) provided on March 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for orthotics on May 18, 2021.  
 
You asked the Plan to waive the coinsurance for orthotics. You say that you want to appeal the amount being 
charged. 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 20% 
coinsurance for durable medical equipment provider. Covered items include, but are not limited to wheelchairs, 
crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a provider for use in the home, 
IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, and walkers. The provider billed 
in the amount of $27,752.33 and the plan paid $22,512.72. For the service it's, $27,752.33 - $22,512.72 = 
$5,239.61. Therefore, results in the total cost sharing amount of $5,239.61. 
 You have been asked to pay a 20% coinsurance for orthotics. This item/service falls within the durable medical 
equipment (DME) and related supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for orthotics on May 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a renal endoscopy (50561), a cystourethroscopy, (52332) and 
a urography (74420). 
 
You asked the Plan to pay for a renal endoscopy, a cystourethroscopy and a urography. You say that you 
disagree with the denial and request payment on the claim. The Plan denied your request. The Plan says the 
records do not support services 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. 
 
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 a renal endoscopy, a cystourethroscopy and a urography. Our 
reviewer says that the services do not meet criteria. Our reviewer found the codes in question are not supported 
by the record. CPT code 50561 is included in 50081, the record does not support that this was a separately 
identifiable procedure. Reporting 50561 with modifier 59 is not supported. CPT code 74420 is not supported. 
The record does not contain evidence of a diagnostic retrograde urography performed during this encounter. 
CPT code 52332 is not supported. The record does not contain evidence that a cystourethroscopy with 
indwelling stent placement was performed during this encounter. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a renal endoscopy, a cystourethroscopy and a urography have not been met. 
Therefore, we decided that the Plan does not have to pay for a renal endoscopy (50561), a cystourethroscopy, 
(52332) and a urography (74420).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for in-network mental health services provide 
from June 15, 2022, to April 12, 2023. 
 
You asked the Plan to waive the coinsurance for in-network mental health services. You say that you are being 
reimbursed for less than half of what you're paying in copayments per visit. You want this changed and want 
the full amount. 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% 
coinsurance for mental health care.  
 
You have a 10% coinsurance for mental health services. Each visit had a $10.27 charge, with 10 visits in the 
date of service range resulting in a total amount of $104.70 ($10.27 x 10 - $104.70). You have been asked to pay a $104.70 coinsurance for in-network mental health services. This item/service 
falls within the mental health 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 coinsurance for 
in-network mental health services provide from June 15, 2022, to April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve the office visit. You say that you are unsatisfied with the network providers 
and would like to be seen by an out-of-network provider. The Plan denied your request. The Plan says there are 
multiple network providers who can provide this service. 
 
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 
the office visit to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on May 
17, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the provider is not 
responding to your concerned and they should not be paid. 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 physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for a 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. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit provided on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 13, 2022. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on December 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on April 19, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you think 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 $40 
copayment for in-network provider and professional services provided in a specialists office. 
 
You have been asked to pay a $40 copayment for an office visit. This item/service falls within the in-network 
provider and professional services provided in a specialists office 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 office visit provided on April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a residence visit. provided on April 11, 2023. 
 
You asked the Plan to pay for a residence visit.. You say that the facility is responsible to obtain prior 
authorization. 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 a residence visit. 
provided on April 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the enrollee requires a group 3 
power mobility base over a group 2 base in order to accommodate 3 power functions including power tilt, 
power recline and power elevating legs. You also say that the enrollee requires these positioning modifications 
due to their aggressive multiple sclerosis, chronic pain, gastric pacer placed right below left ribs, and tube for 
nutrition and hydration. The Plan denied your request. The Plan says there is not a unique need that should 
make this request exempt from the guideline criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-
covered because is not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and transitional care management services 
provided on March 07, 2023, to March 21, 2023. 
 
You asked the Plan to pay for an office visit, and transitional care management services. You say that these 
services were 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, and 
transitional care management services provided on March 07, 2023, to March 21, 2023.