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

 
We decided that the Plan does not have to reduce the cost sharing amounts for the nuclear medicine study 
(78452), stress test (93017), and regadenoson injection (J2785) provided on May 15, 2023. 
 
You asked the Plan to reduce the cost sharing amounts for the nuclear medicine study, stress test, and 
regadenoson injection. You say that the allowable amount is grossly unreasonable for the 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for outpatient diagnostic tests, a $20 copayment for Medicare-covered non-radiological diagnostic 
services, and 20% coinsurance for all Medicare-covered Part B drugs other than allergy antigens.  
 
You have been asked to pay a $90 copayment for the nuclear medicine study which falls within the outpatient 
diagnostic tests benefit category, a $20 copayment for the stress test falls within the Medicare-covered non-
radiological diagnostic services benefit category, and $48.92 for the regadenoson injection falls within the 
Medicare-covered Part B prescription drugs 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 cost sharing 
amounts for the nuclear medicine study (78452), stress test (93017), and regadenoson injection (J2785) 
provided on May 15, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Orencia infusions provided from January 12, 
2023, to July 20, 2023. 
 
You asked the Plan to waive the cost share for Orencia infusions. You say that you should not be assessed a 
coinsurance because the services are covered by Medicare and the cost share applied is more than you can 
afford. The Plan denied your request. The Plan says this cost sharing was charged correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs and a $25 copayment for each specialist visit.  
 
You have been asked to pay $2,332.50 for Orencia infusions.  
 
Date of Service Services 
Rendered 
Amount 
Allowed 
Amount per 
Contract 
Enrollee Share 
January 12, 2023 Orencia Injection $3,250.54 20% coinsurance $650.11 
January 12, 2023 Specialist visit $69.10 $25 copayment $25 
January 26, 2023 Orencia Injection $3,264.32 20% coinsurance $652.86 
January 26, 2023 Specialist visit $64.88 $25 copayment $25 
February 9, 2023 Orencia Injection $3,269.06 20% coinsurance $653.81 
February 9, 2023 Specialist visit $64.88 $25 copayment $25 
March 9, 2023 Orencia Injection $3,269.06 20% coinsurance $300.72 (the total is less 
than the standard amount 
because your out-of-pocket 
maximum was met) 
Total     $2,332.5 
 
The injections fall within the Medicare Part B prescription drugs benefit category. The specialist visits fall 
within the 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. Therefore, we decided that the Plan does not have to waive the cost share 
for Orencia infusions provided from January 12, 2023, to July 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), and prophylaxis - adult (D1110) provided on May 1, 2023. 
 
You asked the Plan to pay for the comprehensive oral evaluation and prophylaxis. You say that you paid in full 
for the services and are requesting reimbursement. The Plan denied your request. The Plan says we are not able 
to process this request without proof of payment. The Plan also says the information provided is for a resin-
based composite, two surfaces, that was completed on June 7, 2023. 
 
 
 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 comprehensive oral evaluation and 
prophylaxis have been met. Without this necessary information, we are unable to determine whether the criteria 
for coverage have been met and whether payment is due. The Plan confirmed that no additional information as 
provided by the office, or you are showing that payment for the services rendered on May 1, 2023 were paid in 
full. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or 
established patient (D0150), and prophylaxis - adult (D1110) provided on May 1, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic anoscopy (46601), diagnostic anoscopy and 
biopsy (46607), and cytopathology (88112) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the diagnostic anoscopy, diagnostic anoscopy and biopsy, and 
cytopathology. You say that you have already had the services completed. You also say that you were informed 
to go, and nobody contacted you to tell you there was no authorization on file for appointment. The Plan denied 
your request. The Plan says the requested facility is not contracted with the Plan, and the services do not meet 
the criteria for urgent or emergent nor for the need to see a specialist outside of the Plan's network providers. 
 
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 
a diagnostic anoscopy (46601), diagnostic anoscopy and biopsy (46607), and cytopathology (88112) to be 
provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an ILR device (33285). 
 
You asked the Plan to pre-approve an ILR. You say that an ILR is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an ILR. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee, with no recent unexplained syncope or cryptogenic cerebral vascular accident, does not 
meet the currently acceptable appropriateness criteria for an implantable loop recorder. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve placement of an ILR device (33285).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on March 01, 2023. 
 
You asked the Plan to pay for the laboratory service. 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 laboratory service 
provided on March 01, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services reported with DRG 280 rendered from 
November 8, 2022, to November 15, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says that the DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 280. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were supported by the medical records. Our physician reviewer found that 
the enrollee had confirmed sepsis with culture-positive bacteremia with an NSTEMI requiring cardiac 
catheterization with multiple major comorbidities. Thus, A41.9, R65.20, and DRG 280 are supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services reported with DRG 280 rendered from November 8, 2022, to November 15, 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 pay for the home visit provided on April 24, 2023. 
 
You asked the Plan to pay for the home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. 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 home visit provided 
on April 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 06, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services should be covered. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on June 06, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
June 08, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this was routine and 
should not have this additional fee. 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 $250 
copayment for in-network outpatient surgery provided at an ambulatory surgical center.. 
 
You have been asked to pay a $250 copayment for the diagnostic colonoscopy. This item/service falls within the in-network outpatient surgery 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. The record shows the procedure was 
billed as a colonoscopy with polyp removal (code 45385), and the outpatient surgery copayment was applied 
correctly. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic 
colonoscopy provided on June 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a nail debridement procedure provided on 
May 10, 2023. 
 
You asked the Plan to reduce the copayment for a nail debridement procedure. You say that the procedure was 
too expensive. 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 in-network podiatry services. 
 
You have been asked to pay a $25 copayment for a nail debridement procedure. This item/service falls within 
the in-network podiatry 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 reduce the copayment for a 
nail debridement procedure provided on May 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on April 27, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on April 27, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance service and the SNF stays 
provided from October 29, 2021, to December 10, 2021. 
 
You asked the Plan to waive the copayments for the ambulance service and the SNF stays. You say that you are 
not convinced you need to pay these claims. 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). The enrollees contract with the Plan clearly says that the enrollee 
must pay a $250 copayment for each one-way ambulance transport. The enrollees contract with the Plan also 
clearly says that the enrollee must pay a $0 copayment per day for days 1-20 and a $165 copayment per day for 
days 21-100 of each benefit period for SNF stays. 
 
The enrollee has been asked to pay a $250 copayment for the ambulance service provided on October 29, 2021. 
This item/service falls within the ambulance services benefit category. The enrollee was provided a total of 35 
days of SNF care. The enrollee has been asked to pay a $0 copayment per day for days 1-20 and a $165 
copayment per day for days 21-35 of this benefit period. The enrollee has been asked to pay $2,475 for the 
SNF care ($165 copayment per day x 15 days = $2,475). This item/service falls within the skilled nursing 
facility care benefit category. 
 
The enrollee has been asked to pay a total of $2,725 ($250 copayment + $2,475 copayment = $2,725). This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay when they enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayments for the ambulance service and the SNF stays 
provided from October 29, 2021, to December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the care management provided on May 22, 2023. 
 
You asked the Plan to pay for the care management. You say that the enrollee was residing in a nursing facility 
when services were 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 the care management 
provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
February 3, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99223 remains not supported. 
 
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 99223 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded." 
 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level or that 75 minutes 
were spent. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on February 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on May 9, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiovascular monitoring services on 
April 05, 2023, to May 11, 2023.  
 
You asked the Plan to waive the copayment for cardiovascular monitoring 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for other outpatient diagnostic tests. Covered services include but are not limited to other outpatient 
diagnostic tests. The allowed amount is $12.83. This is less than the copayment amount. For both dates of 
service, its $12.83 + $15 = $27.83. Therefore, results in the total cost sharing amount of $27.83. 
 You have been asked to pay a $15 copayment and a $12.83 copayment, which is less than the copayment for 
cardiovascular monitoring services. This item/service falls within the outpatient diagnostic tests and therapeutic 
services and supplies benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
cardiovascular monitoring services on April 05, 2023, to May 11, 2023.