Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the urography procedure and the 
cystourethroscopy procedure provided on March 18, 2023. 
 
You asked the Plan to waive the cost share for the urography procedure and the cystourethroscopy procedure. 
You say that you had met your annual deductible and coinsurance amount prior to these services. 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 inpatient hospital care. Your 
contract with the Plan also clearly says that you must pay 10% of the approved amount for inpatient hospital 
care. 
 
You have been asked to pay $2.41, which is 10% coinsurance of the allowed amount for the urography ($24.07 
allowed amount x 10%= 2.41). The remaining allowed amount is $21.66 ($24.07 allowed amount - $2.41 
coinsurance = $21.66). You have also been asked to pay $41.17, which is 10% coinsurance of the allowed 
amount for the cystourethroscopy procedure ($401.74 allowed amount x 10% = 41.17). The remaining allowed 
amount is $360.57 ($401.74 allowed amount - $41.17 coinsurance = $360.57). These items/services fall 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. 
 
You have also been asked to pay $21.66 towards your deductible for the urography. You have also been asked 
to pay $360.75 towards your deductible for the cystourethroscopy procedure. These items or services you asked 
the Plan to waive the cost share for falls within the inpatient hospital care benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $800 deductible which applies to 
inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time the 
urography procedure and the cystourethroscopy procedure was received on March 18, 2023. Therefore, we 
decided that the Plan does not have to waive the cost share for the urography procedure and the 
cystourethroscopy procedure provided on March 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for advanced imaging services provided on 
July 10, 2023. 
 
You asked the Plan to waive the copayment for advanced imaging services. You say that you are requesting 
reconsideration for the denied claim. 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 
$118.23 copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $118.23 copayment for advanced imaging 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 advanced imaging services provided on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the anticoagulant management services 
provided on March 28, 2023, to May 10, 2023. 
 
You asked the Plan to waive the copayment for the anticoagulant management services. 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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for the anticoagulant management 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. However, since the allowed amount is 
less than the standard copayment, you only owe $9.92 for each service. The total amount you owe is $69.44 
($9.92 copayment x 7 services = $69.44). Therefore, we decided that the Plan does not have to waive the 
copayment for the anticoagulant management services provided on March 28, 2023, to May 10, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
January 1, 2023. 
 
You asked the Plan to pay for the ED services. You say that you would like to request reconsideration for 
payment. 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 January 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a targeted genomic sequence analysis panel, 
hematolymphoid neoplasm or disorder, 5-50 genes (81450). 
 
You asked the Plan to pre-approve a targeted genomic sequence analysis panel, hematolymphoid neoplasm or 
disorder, 5-50 genes. 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 follows Medicare rules. Medicare rules say that genetic testing is covered when specific criteria are 
met. 
 
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 targeted genomic sequence analysis 
panel, hematolymphoid neoplasm or disorder, 5-50 genes. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found there is no documentation of cytopenia for greater than four months 
without a known cause (undefined cytopenia) and other possible causes have been reasonably excluded. The 
review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
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 targeted genomic sequence analysis panel, hematolymphoid neoplasm or 
disorder, 5-50 genes have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, 5-50 genes (81450).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 14, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says you got the service from a provider who chose not to 
receive Medicare funds. This means they're on the Medicare opt-out list. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit provided on June 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
October 27, 2022, through December 13, 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 the acute inpatient psychiatric hospital care 
provided was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was involuntarily admitted for acute inpatient psychiatric hospitalization on October 27, 2023 
with Major Neurocognitive Disorder, Unspecified with Behavioral Disturbance. Based upon the review of the 
records provided, it was not expected that this enrollee would improve in a reasonable period of time as she did 
not have dangerousness to self or others and was not showing any auditory/visual hallucinations or any 
aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at 
the acute inpatient level of care rather than a lower level of care as she did not have dangerousness to self or 
others. The health plans denial of inpatient psychiatric services appears appropriate. This enrollee did not 
appear to require inpatient mental health treatment as she was not a danger to herself or others and was 
cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking 
place. It did not appear that the services were reasonably expected to improve the enrollees condition or were 
for the purpose of a diagnosis. It did appear that the records were supervised and evaluated by a physician. 
Based upon the review of the records provided the enrollee does not meet criteria for coverage of the acute 
inpatient mental health treatment provided as she was not shown to be a danger to herself or others, and did not 
have auditory or visual hallucinations. She was noted to be cooperative and compliant with treatment while not 
showing any aggressive behaviors. 
 
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 pay for the acute inpatient psychiatric hospital care provided from October 27, 2022, through 
December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging provided on June 01, 2023. 
 
You asked the Plan to pay for the magnetic resonance imaging. You say that you are appealing the denial with 
supporting documentation. 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 magnetic resonance 
imaging provided on June 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 05, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on January 05, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic mammogram, the breast ultrasound, and the 
diagnostic digital breast tomosynthesis provided on July 03, 2023, to July 19, 2023. 
 
You asked the Plan to pay for the diagnostic mammogram, the breast ultrasound, and the diagnostic digital 
breast tomosynthesis. 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 diagnostic 
mammogram, the breast ultrasound, and the diagnostic digital breast tomosynthesis provided on July 03, 2023, 
to July 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on June 28, 2023. 
 
You asked the Plan to pay for the home visit. 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 home visit provided 
on June 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee arthroscopy and the injections provided on April 18, 
2023. 
 
You asked the Plan to pay for the knee arthroscopy and the injections. You say that you say that the services 
were provided in good faith. 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 knee arthroscopy 
and the injections provided on April 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an out-of-network ambulance ride 
provided on August 05, 2023. 
 
You asked the Plan to reduce the copayment for an out-of-network ambulance ride. You say that you didnt 
know that this ambulance was out-of-network. You needed help so you called. 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 $325 
copayment for ambulance services. 
 
You have been asked to pay a $325 copayment for an out-of-network ambulance ride. This item/service falls 
within the ambulance 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 an out-of-
network ambulance ride provided on August 05, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network colonoscopy provided on 
August 01, 2023. 
 
You asked the Plan to waive the copayment for an in-network colonoscopy. You say that this must be a coding 
error, as this was a screening colonoscopy. 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 $375 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $375 copayment for an in-network colonoscopy. This item/service falls within 
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
However, since the allowed amount is less than the standard copayment, you only owe $294.72. Therefore, we 
decided that the Plan does not have to waive the copayment for an in-network colonoscopy provided on August 
01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on March 31, 2023. 
 
You asked the Plan to pay for drug testing. You say that this testing was medically necessary. 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 drug testing provided on 
March 31, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring 
provided on July 09, 2023. 
 
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring. 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 continuous 
intraoperative neurophysiology monitoring provided on July 09, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an network acute inpatient stay provided on 
April 01, 2023, to April 11, 2023. 
 
You asked the Plan to waive the copayment for an network acute inpatient stay. You say that you were not 
aware that you had a copayment for each day you were hospitalized. 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 for inpatient hospital care.  
You have been asked to pay a $300 copayment for an network acute inpatient 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. You have been asked to pay a total of $1,500 for the inpatient hospital stay 
($300 copayment x 5 days = $1,500). You have not been charged for the day you were discharged. Therefore, 
we decided that the Plan does not have to waive the copayment for an network acute inpatient stay provided on 
April 01, 2023, to April 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on July 31, 2023. 
 
You asked the Plan to pay for a home visit. You say that the services rendered were medically necessary. 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 a home visit provided on 
July 31, 2023.