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

 
We decided that the Plan does not have to waive the copayment for the inpatient stay provided on September 
23, 2023, to September 30, 2023. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that the cardiologist did not see any 
reason that you could not be released. 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 inpatient hospital care. 
 
You have been asked to pay a $250 copayment for the inpatient stay. This item/service falls within the in-network 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. You have been asked to pay a total of $1,500 ($250 copayment x 6 days = 
$1,500). Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay 
provided on September 23, 2023, to September 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is expedited to be able to tolerate and 
benefit from an intensive coordinated rehabilitation program. The Plan denied your request. The Plan says the 
services the enrollee needs can be provided safely in other settings, for example, a skilled nursing facility 
(SNF), home with home health services or home with outpatient therapy.  
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the naturopathic services provided on 
September 12, 2023. 
 
You asked the Plan to waive the coinsurance for the naturopathic services. You say that the cost share is wrong. 
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 50% 
coinsurance for Naturopathic services. 
 
You have been asked to pay 50% coinsurance for the naturopathic services. This item/service falls within the 
Naturopathic 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 the 
naturopathic services provided on September 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service August 31, 
2023. 
 
You asked the Plan to pay for procedure code 87640. You say that medical records were provided. The Plan 
denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 
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, we have confirmed that code 87640 is a column II code to column I code 87641. The records show 
that a respiratory pathogen panel test was provided. The records do not show that code 87640, billed with the -
59 modifier, was a separate and distinct procedure. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87640 billed 
for date of service August 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have  to waive the copayment for each diagnostic tests and physician service 
and the coinsurance for each Medicare Part B drug and outpatient surgery 
 
You asked the Plan  to waive the copayment for each diagnostic tests and physician service and the coinsurance 
for each Medicare Part B drug and outpatient surgery. You say that the cost share is wrong. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each Medicare Part B drugs, a $35 copayment for each diagnostic tests with a specialist, $35 
copayment for each physician service, and 40% coinsurance for each surgery service. You have been asked to pay a 20% coinsurance for each Medicare Part B drugs, a $35 copayment for  each 
diagnostic tests with a specialist, a $35 copayment for each physician services, and a40% coinsurance for each 
surgery services. 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 each diagnostic tests and 
physician service and the coinsurance for each Medicare Part B drug and outpatient surgery
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that  admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care 
and does not require transfer to a long-term acute care hospital. 
 
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 not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is on supplemental oxygen via nasal cannula, has non-complex wound 
care needs and does not meet LTACH admission criteria. 
 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 not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee as age-related osteoporosis 
without current pathological fracture. She was previously treated with alendronate but could not tolerate it due 
to gastrointestinal distress. She has not tried and failed the Plan's required drug, zoledronic acid. The records do 
not show that the required drug would likely be less effective and/or would have adverse effects. Prolia is 
therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 12, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered test. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will reimburse approved tests covered 
for dates of service consistent with the effective date of the coverage determination. 
 
We looked at the file and Medicare rules. The Tempus xG 52 gene panel provided in this case is not covered 
under the DEX Diagnostics Exchange. As such, this test is not payable in this case. Based on this information, 
we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the genetic testing provided on July 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 25, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Shingles vaccine. 
 
You asked the Plan to pre-approve the Shingles vaccine. You say that this vaccine is medically necessary. The 
Plan denied your request. The Plan says this is not a covered service under the Part B medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Shingles 
vaccine. Therefore, we decided that the Plan does not have to pre-approve a Shingles vaccine.  
 
Benefits for the Shingles vaccine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a Freestyle Libre. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on April 2, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
the enrollee was evaluated in the emergency department (ED) after falling. A limited history and appropriate 
physical examination were documented. The medical decision making was not of high complexity.  As such, 
the billing of CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on April 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital observation services described by code G0378 
billed for dates of service August 21, 2023, and August 22, 2023. 
 You asked the Plan to pay for G0378. You say that all units of G0378 should be paid as billed because they are 
supported in the documentation. The Plan denied your request. The Plan says G0378 is denied because the 
provider reported hospital observation services for fewer than 8 hours, which is not reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that payment will not be made when the hours of 
observation care reported are less than 8. 
 
We looked at the file and Medicare rules. In this case, we confirmed that the claim in question was submitted 
with 2 units of code G0378. By definition, this code indicates hopsital observation services per hour, with 1 
unit correlating to 1 hour of observation. Therefore, 2 units of this code would indicate 2 hours of observation. 
Per Medicare rules, payment for observation services coded as G0378 will not be made if the hours of 
observation care are reported to be less than 8, as is the case here. Based on this information, we decided that 
Medicare rules for coverage of G0378 have not been met. Therefore, we decided that the Plan does not have to 
pay for the hospital observation services described by code G0378 billed for dates of service August 21, 2023, 
and August 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on April 
21, 2023, to April 30, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
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 $225 
copayment for inpatient hospital care. 
 
You have been asked to pay a $225 copayment for inpatient hospital care. 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. The total amount you owe is $1,350 ($225 x 6 days = $1,350). Therefore, we decided that 
the Plan does not have to waive the copayment for inpatient hospital care provided on April 21, 2023, to April 
30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee.  The Plan denied your request. The Plan says the enrollee's condition does not meet all the 
requirements for LTACH 
 
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 not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is not on the ventilator, has non-complex wound care, and does not 
require at least 6.5 hours of skilled nursing per day and does not meet LTACH admission criteria. 
 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 not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 1, 2023. 
 
You asked the Plan to pay for the ED services. You say that you believe this claim should be processed. The 
Plan denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on September 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and a 
specialist office visit provided on August 17, 2023. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and a specialist office visit. 
You say that you disagree with 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs. Also, a $20 copayment for physician/practitioner 
services/specialist.  
 You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $20 copayment 
for a specialist office visit. The total allowed amount for the prescription drugs is $2,658.61. You are being 
asked to pay is $531.72 (2,658.61 x 20 % = $531.72). The total amount you are being asked to pay is $551.72 
($531.72 + $20 = $551.72). This item/service falls within the Medicare Part B prescription drugs and 
physician/practitioner services/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 cost share 
for Medicare Part B prescription drugs and a specialist office visit provided on August 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
(71275) provided on March 20, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan (71275). You say that the 
cost share is wrong. 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 $150 
copayment for Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for the computed tomography (CT) scan (71275). 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 the computed tomography (CT) scan (71275) provided on 
March 20, 2023.