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

 
We decided that the Plan does not have to waive the coinsurance for outpatient surgery on June 17, 2022.  
 
You asked the Plan to waive the coinsurance for outpatient surgery. You say that you were told by the plan that 
your knee replacement would be covered at 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 30% 
coinsurance for each Medicare-covered outpatient surgery at an outpatient facility. Covered services include 
but are not limited to services in an emergency department or outpatient clinic, such as observation services or 
outpatient surgery. The provider billed in the amount of $8,050 and the coinsurance amount is $4,554.82. The 
provider also billed in the amount of $163 and the coinsurance amount is $35.22 for the service. $4,554.82 + 
$35.22 = $4,590.04. Therefore, resutls in the total cost sharing amount of $4,590.04. 
 
You have been asked to pay a 30% coinsurance for outpatient surgery. This item/service falls within the 
outpatient hospital 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 coinsurance for outpatient 
surgery on June 17, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the copayment for outpatient surgery on February 10, 2023.  
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you thought the insurance is 
supposed to take care of it. The Plan denied your request. The Plan says that 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). The enrollees contract with the Plan says that enrollees must pay a 
$0 copayment for physician/practitioner services, including doctors office visits.  
 
The Plan says the enrollee must pay a 20% coinsurance for outpatient surgery. Based on the plan contract, 
however, the enrollee cannot be asked to pay more than a $0 copayment for outpatient surgery. Therefore, we 
decided that the Plan has to waive the copayment for outpatient surgery on February 10, 2023.   
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has failed at a sub-acute rehabilitation 
level of care and needs intensive rehabilitation therapies at an IRF level of care. You would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says admission to an 
IRF is not medically necessary.  
 
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 the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 20, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 requested 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 pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 20, 
2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ReActiv8 implantable neurostimulator system. 
 
You asked the Plan to pre-approve the ReActiv8 device. You say that you want to appeal this denial. The Plan 
denied your request. The Plan says this 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 the ReActiv8 device. Our reviewer says 
that the requested ReActiv8 device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this device is the subject of an ongoing clinical trial. The reviewer found that the 
enrollee is not enrolled in that trial. Therefore, the requested ReActiv8 device is not medically reasonable and 
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 the ReActiv8 device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the ReActiv8 implantable neurostimulator system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (E0652) 
and segmental pneumatic appliances (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that the medical 
records provided support the necessity of the requested service. The Plan denied your request. The Plan says 
the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week 
trial of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a Flexitouch pneumatic 
compression device (E0652) and segmental pneumatic appliances (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote patient monitoring provided on March 14, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the remote patient monitoring. You say that this service was medically 
necessary. The Plan denied your request. The Plan says enrollees must receive their 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the item/service 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 pay for this item/service. Therefore, 
we decided that the Plan does not have to pay for the remote patient monitoring provided on March 14, 2023, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 23, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration. 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 March 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service March 3, 
2023.  
 
You asked the Plan to pay for procedure code 88377. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88377 is 5. The MAI value for this code is 3. You billed 11 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88377 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88377 billed for date of service March 3, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from January 11, 2023, to February 15, 
2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
eligible to bill Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the services provided from January 11, 
2023, to February 15, 2023.
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 January 
25, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you just asked a question, 
and you should not be charged for a specialist office 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 physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 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 January 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
September 2, 2022, to September 8, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that your surgeon told you 
that you would only have to stay one day in the hospital. 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 $300 
copayment per day for days 1-6 of each in-network inpatient hospital stay. Your contract with the Plan clearly says that you then pay a $0 copayment per day for days 7-90 of each in-network inpatient hospital stay. 
 
You have been asked to pay a $300 copayment per day for days 1-5 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been asked to pay after day 
five or for the day you were discharged. You have been asked to pay a total of $1,500 for the inpatient hospital 
stay ($300 copayment per day x 5 days = $1,500). 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 inpatient hospital stay provided from September 2, 2022, to September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 3, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on February 11, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
February 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on February 27, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
February 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6545. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the requested items 
are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
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 compression stockings. Our 
reviewer says that these items are not medically necessary. Our physician reviewer found that the 
documentation does not support that you have any open wounds caused by or treated by a surgical procedure. 
 
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 compression stockings have not been met. Therefore, we decided that the 
Plan does not have to pre-approve compression stockings identified with code A6545.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve the home health services. You say that you are struggling to recover after 
two back surgeries. You also say that it is a struggle to walk short distances without a walker. The Plan denied 
your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you are noted 
to have had lumbar surgery and are experiencing right leg weakness and pain. There is limited clinical 
documentation in terms of your current level of function and mobility as well as the need for home based 
versus outpatient physical therapy. It is unclear if you are confined to the home and have not followed-up with 
your surgeon. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mavenclad. 
 
You asked the Plan to pre-approve the medication. You say that this medication is medically necessary for the 
ernollee. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 The Plan must follow Medicare rules. 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 pre-approve Mavenclad.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 17, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration with supporting 
documents. 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 17, 2023.