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

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on August 24, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you do not 
believe you should be responsible for the copayment assessed. 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 $200 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $200 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests 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 
computed tomography (CT) scan provided on August 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT Peripheral Nerve Stimulation (PNS) device. 
 
You asked the Plan to pre-approve a SPRINT PNS device. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested device 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 a SPRINT PNS device. 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 neck pain. The enrollee takes Gabapentin, Tylenol, 
Cymbalta, Topamax and methocarbamol for pain. The enrollee had an attempted cervical spinal cord 
stimulation placement but due to prior cervical spine surgery, the placement was not successful. The requested 
would be considered experimental/ investigational for the treatment of neck pain. Therefore, the enrollee does not meet criteria for the requested device. 
 
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 SPRINT PNS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a SPRINT Peripheral Nerve Stimulation (PNS) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on August 09, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that wound care supplies are a separately billable 
expense that does not require authorization or referral. 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 wound care supplies 
provided on August 09, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing billed with code G0482 for date of service 
April 26, 2023. 
 
You asked the Plan to pay for the drug testing billed with code G0482. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says definitive confirmation testing was medically 
necessary for only one drug class. 
 
The Plan follows Medicare rules. Medicare rules say that drug testing is only covered for certain indications. 
 
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 drug testing billed with code G0482. Our 
reviewer says that the documentation does not support that the services rendered were medically reasonable or 
necessary. Our physician reviewer found the enrollee was referred for extensive confirmatory drug testing. The 
documentation does not support that extensive confirmatory drug testing was medically necessary. Therefore, 
the enrollee did not meet criteria for the requested testing. 
 
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 drug testing billed with code G0482 have not been met. Therefore, we 
decided that the Plan does not have to pay for the drug testing billed with code G0482 for date of service April 
26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87486, 87498, 87502, 87541, 87581, 87634, 
87635, 87640, 87798) provided on May 18, 2023. 
 
You asked the Plan to pay for the lab services. 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 a test panel is a single test with multiple 
components and is characterized by a single unit of service. A panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. 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 lab services (87486, 87498, 87502, 87541, 87581, 87634, 
87635, 87640, 87798) provided on May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the genetic testing provided on April 21, 
2023. 
 
You asked the Plan to waive the coinsurance for the genetic testing. You say that this service was medically 
necessary. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for the genetic testing. 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. The total amount you owe is $700 ($3,500 allowed 
amount x 20% = $700). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
genetic testing provided on April 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for remote patient monitoring provided on July 
19, 2023. 
 
You asked the Plan to waive the copayment for remote patient monitoring. You say that you already paid an 
office visit copayment, and you did not have any diagnostic test  done. 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 $15 
copayment for physician/practitioner services, including doctors office visits.. 
 
You have been asked to pay a $15 copayment for remote patient monitoring. 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 remote patient monitoring provided on July 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the dressing and/or debridement of a burn 
provided on March 29, 2023. 
 
You asked the Plan to reduce the copayment for the dressing and/or debridement of a burn. You say that you 
feel that the enrollees copayment should be lower. 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 $275 
copayment for in-network surgical services provided at an ambulatory surgical center. 
 
You have been asked to pay a $275 copayment for the dressing and/or debridement of a burn. This item/service falls within the in-network surgical services provided at an ambulatory surgical center benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to reduce the copayment for the dressing and/or debridement of a burn provided on 
March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99232) provided on March 10, 2023. 
 
You asked the Plan to pay for the hospital care. 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. 
 
In this case, the CPT Code Manual definition of code 99232 is subsequent hospital inpatient or observation 
care. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, the billed service is a 
hospital service, however the claim was billed with place of service 31- Skilled Nursing Facility. Based on this 
information, we decided that Medicare rules for coverage of the hospital care have not been met. Therefore, we 
decided that the Plan does not have to pay for hospital care (99232) provided on March 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the nasal endoscopy provided on June 19, 
2023, to July 10, 2023. 
 
You asked the Plan to pay for the office visit and the nasal endoscopy. 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 and the 
nasal endoscopy provided on June 19, 2023, to July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 13, 2023, to March 
21, 2023. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the services are not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, a notice of denial of payment has not been provided, as well as complete medical 
records for the dates of service in question. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on March 13, 2023, to March 21, 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 August 
02, 2023. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you feel that you should not 
be responsible for your urgent care 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 urgently needed services. 
 
You have been asked to pay a $30 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 August 02, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
June 27, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you do not 
understand why the cost share was not paid by 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an emergency room (ER) visit. This item/service 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. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room 
(ER) visit provided on June 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a continuous positive airway pressure 
(CPAP) device provided on January 14, 2023, to July 14, 2023. 
 
You asked the Plan to reduce the coinsurance for a continuous positive airway pressure (CPAP) device. You 
say that you think that the cost sharing should be lower. 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 40% 
coinsurance for out-of-network Medicare-covered oxygen equipment. 
 
You have been asked to pay 40% coinsurance for a continuous positive airway pressure (CPAP) device. This 
item/service falls within the out-of-network Medicare-covered oxygen equipment 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 total you owe is $187.60 ($468.93 
allowed amount x 40% = $187.57). Therefore, we decided that the Plan does not have to reduce the 
coinsurance for a continuous positive airway pressure (CPAP) device provided on January 14, 2023, to July 14, 
2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health counseling provided on July 11, 2023, to 
July 18, 2023. 
 
You asked the Plan to pay for the mental health counseling. You say that you want to appeal because you are 
receiving bills from the provider. 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 mental health 
counseling provided on July 11, 2023, to July 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan of extremity veins provided 
on May 31, 2023. 
 
You asked the Plan to waive the copayment for the duplex scan of extremity veins. You say that that there is no 
explanation why the plan paid nothing and you owe more than the amount allowed. 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 $115 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $115 copayment for the duplex scan of extremity veins. 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. However, since the allowed amount is 
less than the standard copayment, you only owe $100.47. Therefore, we decided that the Plan does not have to 
waive the copayment for the duplex scan of extremity veins provided on May 31, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria. The Plan denied your request. The Plan says that the request is not medically necessary. 
 
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 considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has stabilized to the point where they do not require further care in the acute 
care hospital. However, their needs are too complex to be met at lower 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 the LTACH services have been met. Therefore, we decided that the Plan has to 
pre-approve LTACH services.  
 
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 pay for the chiropractic care provided on August 02, 2023. 
 
You asked the Plan to pay for the chiropractic care. You say that you say that you have attached medical 
records 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 the chiropractic care 
provided on August 02, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on June 20, 
2023, to July 14, 2023. 
 
You asked the Plan to waive the copayment for physical therapy. You say that if you were to have known the 
copayment was $40, you would have never went. 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 outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for physical therapy. This item/service falls within the outpatient rehabilitation 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. You have been asked to pay a total of $200 for the outpatient rehabilitation services for 
date of service June 20, 2023 to July 14, 2023 ($40 copayment x 5 physical therapy visits = $200). Therefore, 
we decided that the Plan does not have to waive the copayment for physical therapy provided on June 20, 2023, 
to July 14, 2023.