Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for the CPAP supplies provided on May 1, 
2023. 
 
You asked the Plan to reduce the deductible for the CPAP supplies. You say that you had already met your 
deductible prior to this service. 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 durable medical equipment and 
related supplies.  
 
 
 
 
 
 You have been asked to pay $189.51 towards your deductible for the supplies. The item or service you asked 
the Plan to reduce the deductible for falls within the durable medical equipment and related supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to durable medical equipment and related supplies. This cost sharing is a contractual 
obligation that had not been met at the time the CPAP supplies was received on May 1, 2023. Therefore, we 
decided that the Plan does not have to reduce the deductible for the CPAP supplies provided on May 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 05, 
2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing 
facility care provided on June 05, 2023.
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 May 01, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that the provider 
advised you the $75 payment had already been made prior to the services being rendered. 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 $75 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $75 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 May 01, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the diagnostic mammogram, the digital 
breast tomosynthesis, and the breast ultrasound provided by an in-network provider on May 17, 2023. 
 
You asked the Plan to waive the deductible for the mammogram, the digital breast tomosynthesis, and the 
ultrasound. You say that you should not be liable for the cost share. 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 $800 deductible which applies to the mammogram, the digital breast 
tomosynthesis, and the ultrasound. 
 
 
 
 
 You have been asked to pay a $319.53 deductible for the mammogram, the digital breast tomosynthesis, and 
the ultrasound. The items or services you asked the Plan to waive the deductible for fall within the hospital 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $800 deductible which applies to hospital services. This cost sharing is a contractual obligation that had not 
been met at the time the mammogram, the digital breast tomosynthesis, and the ultrasound were provided on 
May 17, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the diagnostic 
mammogram, the digital breast tomosynthesis, and the breast ultrasound provided by an in-network provider 
on May 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bariatric surgery to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve bariatric surgery. You say that you are requesting reconsideration for the 
service. The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives 
from an out-of-network provider (a provider who is not part of the plans network) will not be covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
bariatric surgery to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 31, 2022, billed 
with codes 81314, 81345, and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that the treatment sought was medically 
necessary. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
The file shows that a comprehensive complete cancer panel was provided. We looked at the file and Medicare 
rules. This panel testing was not billed with a single code as required. Based on this information, we decided 
that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the genetic testing provided on December 31, 2022, billed with codes 81314, 
81345, and 81272.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty procedures (22513, 22514). 
 
You asked the Plan to pre-approve a kyphoplasty. You say that a kyphoplasty is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested services are 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 kyphoplasty. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that detailed documentation is not evident in the case record regarding acute or subacute 
fractures at all of the requested treatment levels. Additionally, there is no documentation of a progression of the 
body height loss, kyphotic deformity or a severe impact on daily activities. Moreover, there is magnetic 
resonance imaging (MRI) scan corroboration of other plausible causes of pain. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty procedures (22513, 22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on April 12, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you do not understand why you are 
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 $15 
copayment for each covered visit or consultation in an outpatient location with a specialist. 
 
You have been asked to pay a $15 copayment for an office visit. This item/service falls within the each covered 
visit or consultation in an outpatient location with a specialist 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 12, 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 07, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you do not feel 
liable for the cost share applied because the facility did not handle you with proper care. 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 $100 
copayment for emergency care. 
 
You have been asked to pay a $100 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 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for anesthesia services on May 24, 2023. 
 
You asked the Plan to waive the deductible for anesthesia services. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to outpatient surgery, including 
services provided at hospital facilities and ambulatory surgical centers.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient surgery, including 
services provided at hospital facilities and ambulatory surgical centers benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to outpatient 
surgery, including services provided at hospital facilities and ambulatory surgical centers. This cost sharing is a 
contractual obligation that had not been met at the time anesthesia services was received on May 24, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for anesthesia services on May 24, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on November 30, 2022. 
 
You asked the Plan to pay for lab testing. You say that you say that the services were medically necessary and 
therefore payable. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
November 30, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from November 30, 2022, 
through December 7, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee with multiple past medical problems including diabetes, hypertension, and heart failure 
presented with increasing shortness of breath in spite of treatment at home with albuterol and steroids. She was 
found to have possible acute heart failure, pneumonia, and kidney injury and was hospitalized for further care 
including intravenous diuretics, antibiotics, and consultation with nephrology. The records reflect a clear intent 
by her admitting physician to manage the enrollee over a minimum stay of two midnights due to the severity of 
her condition and presence of kidney injury, which complicates the management of her heart failure and 
diabetes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from November 30, 2022, through December 7, 2022.  
 
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 chiropractic manipulative treatment; spinal 
(98940) provided on April 12, 2023, to April 27, 2023. 
  
You asked the Plan to waive the cost share for chiropractic manipulative treatment; spinal (98940) and 
chiropractic manipulative treatment; extraspinal (98943). You say that you feel you were not charged correctly 
because the Medicare and You book says nothing about services being non-covered when it is not the spine. 
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 in-
network copayment per visit. 
 
You have been asked to pay a total of $80 for chiropractic manipulative treatment; spinal (98940) (4/visits x 
$20 = $80). This item/service falls within the chiropractic 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 chiropractic manipulative treatment; spinal (98940) provided on April 12, 2023, to 
April 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0481) provided on January 26, 
2023. 
 
You asked the Plan to pay for drug testing. You say that this testing was necessary and is supported as billed. 
The Plan denied your request. The Plan says there is insufficient information to support that the services 
provided were requested by the enrollee's treating physician and were medically necessary. 
 
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 drug testing have been met. 
Specifically, the physician order provided does not indicate that all of the drugs tested were actually requested 
for testing. Therefore, we decided that the Plan does not have to pay for definitive drug testing (G0481) 
provided on January 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on April 23, 2023, to May 20, 
2023. 
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration for 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 home health services 
provided on April 23, 2023, to May 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on May 29, 2023, to 
June 10, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that since you received an 
infection from the hospital you don't feel like you should owe a copay and the hospital should not be paid 
because you feel that they are profiteering for their mistakes. 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 $220 
copayment for per day per admit for days 1 -5 and $0 copayment per day per admit for days 6 -90 for inpatient 
hospital care. Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of 
inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a 
doctors order. The day before you are discharged is your last inpatient day. For the first five days there is a 
$220 copayment per day. 5 x $220 = $1,100. Therefore, results in the total cost sharing amount of $1,100. 
 
You have been asked to pay a $220 copayment per day per admit for inpatient hospital stay. This item/service 
falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
inpatient hospital stay on May 29, 2023, to June 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network specialist visit provided on 
May 24, 2023. 
 
You asked the Plan to waive the copayment for an in-network specialist visit. You say that you saw a 
physicians assistant, not an MD. You should not have to pay this 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 $45 
copayment for Physician/Practitioner services, including doctors officevisits. 
 
You have been asked to pay a $45 copayment for an in-network specialist visit. This item/service falls within 
the Physician/Practitioner services, including doctors officevisits 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 in-network specialist visit provided on May 24, 2023.