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

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service December 8, 
2022.   
You asked the Plan to pay for procedure code 88341. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 14 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service December 8, 2022.
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 you need rehabilitation after your toe 
amputation. The Plan denied your request. The Plan says you are receiving appropriate inpatient acute care and 
are currently unstable for transfer to an 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 there are no services available at the LTACH that you require that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for your diagnosis. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on November 14, 
2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that the Plan should fully cover this 
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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the office visit provided on November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a clinic visit and a laryngoscopy provided on March 02, 
2023. 
 
You asked the Plan to pay for a clinic visit and a laryngoscopy. You say that the service 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 a clinic visit and a 
laryngoscopy provided on March 02, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient surgery and office visit on July 
13, 2022, to August 11, 2022.  
 
You asked the Plan to waive the copayments for outpatient surgery and office visit. 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 $250 
copayment for each Medicare-covered outpatient surgery at an outpatient hospital facility. The Plan covers 
medically necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an 
illness or injury. You must pay a $40 copayment for physician specialist services. Covered services include 
consultation, diagnosis, and treatment by a specialist. $250 + $40 = $290. Therefore, results in the total cost 
sharing amount of $290. 
 
You have been asked to pay a $250 copayment for outpatient surgery and a $40 copayment for office visit. 
This item/service falls within the outpatient hospital services and physician/practitioner services, including 
doctors office visits benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for outpatient surgery 
and office visit on July 13, 2022, to August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital care provided on April 23, 2023, to April 26, 
2023. 
 
You asked the Plan to pay for the hospital care. You say that the enrollee was an inpatient, and 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 hospital care 
provided on April 23, 2023, to April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a negative pressure wound therapy 
(NPWT) pump. 
 
You asked the Plan to pre-approve NPWT pump. You say that continued use of the NPWT pump is medically 
necessary. The Plan denied your request. The Plan says the enrollee has used the NPWT pump for more than 4 
months so continued use is not covered. 
 The Plan must follow Medicare rules. Medicare rules say that continued use of a NPWT pump and supplies 
will be denied after 4 months have elapsed using the NPWT pump in the treatment of the most recent wound. 
 
We looked at the file and Medicare rules. The record shows that the enrollee has used this NPWT pump since 
January 23, 2023; therefore, more than 4 months of use have elapsed. Based on this information, we decided 
that Medicare rules for coverage of NPWT pump have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued use of a negative pressure wound therapy (NPWT) pump.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen.  
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found a positive dipstick should prompt a 
microscopic examination. A positive dipstick is not considered as defining microhematuria and a CT is not 
indicated. No microscopic exam was submitted in this case.  
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the abdomen.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D2392, D2393, D2332, D2394) provided on 
August 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 22, 2022. 
Therefore, we decided that the Plan does not have to pay for extractions (D2392, D2393, D2332, D2394) 
provided on August 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for SNF services provided on October 27, 2022, to 
October 31, 2022. 
 
You asked the Plan to pay more for SNF services. You say that you would like to be reimbursed for your 
member responsibility for the SNF services because you had already met your out-of-pocket maximum. 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 40% 
coinsurance per day, days 1 to 100 for out-of-network SNF care. Your combined maximum out-of-pocket 
amount is $6,700. 
  You have been asked to pay a total of 1,874.49 for SNF services. 
 
Date of Service Service Code Allowed Amount Standard Cost Member Liability 
October 27, 2022  
October 31, 2022 
Room and Board $2,220 40% $888 
October 27, 2022  
October 31, 2022 
Pharmacy - General $1,159.56 40% $463.82 
October 27, 2022  
October 31, 2022 
IV therapy $169.02 40% $67.61 
October 27, 2022  
October 31, 2022 
Supplies and 
Devices 
$16.45 40% $6.58 
October 27, 2022  
October 31, 2022 
Laboratory $232.64 40% $93.06 
October 27, 2022  
October 31, 2022 
Physical therapy - 
general 
$420 40% $168 
October 27, 2022  
October 31, 2022 
Physical therapy - 
evaluation 
$105 40% $42 
October 27, 2022  
October 31, 2022 
Occupational 
therapy 
$375 40% 
 
*$145.42 
Less than 40% 
TOTAL:    $1,874.49 
 
These items/services fall within the skilled nursing facility (SNF) care benefit category. You met the $6,700 
combined out-of-pocket on this claim. 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 pay more for SNF services provided on 
October 27, 2022, to October 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a molecular pathology procedure provided on February 17, 
2023. 
 
You asked the Plan to pay for a molecular pathology procedure. You say that this testing was ordered by a 
physician. 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 molecular pathology 
procedure provided on February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 18, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the tests should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network antigen therapy provided from 
February 10, 2023, to February 14, 2023. 
 
You asked the Plan to waive the copayment for in-network antigen therapy. You say that you were never told 
these treatments would have such high costs. 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 other Medicare Part B nonchemotherapy prescription drugs.  
 
The allowed amount of this drug is $480.06, resulting in a coinsurance amount of $96.12 ($480.06 x 20% = 
$96.12). You had three of these visits, totaling $288.36 ($96.12 x 3 = $288.36). You have been asked to pay a $288.36 coinsurance for in-network antigen therapy. This item/service falls 
within the other Medicare Part B nonchemotherapy 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 waive the copayment for in-network antigen therapy provided from February 10, 2023, to 
February 14, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of teeth (70310) provided on December 28, 
2022. 
 
You asked the Plan to pay for the x-ray exam of teeth. You say that you would like the documents to be 
reviewed in their entirety for proper payment on this code. The Plan denied your request. The Plan says the 
services requested are purely dental in nature, and are unrelated to the limited clinical indications. The Plan 
also says the services are not eligible for coverage under the medical benefit. 
 Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that are 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the x-ray 
exam of teeth (70310) provided on December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for the chiropractic services provided on 
March 10, 2023. 
 
You asked the Plan to reduce the deductible for the chiropractic services. You say that the enrollee should have 
a $20 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. Your 
contract with the Plan says that there is a $550 deductible which applies to chiropractic services.  
 
 The enrollee has been asked to pay $38.91 towards their deductible for the chiropractic services. The item or 
service you asked the Plan to reduce the deductible for falls within the chiropractic services benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $550 deductible which 
applies to chiropractic services. This cost sharing is a contractual obligation that had not been met at the time 
the chiropractic services was received on March 10, 2023. Therefore, we decided that the Plan does not have to 
reduce the deductible for the chiropractic services provided on March 10, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 test kit (K1034) 
provided on February 1, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test kit. You say that you would like this claim to be 
reconsidered for payment. The Plan denied your request. The Plan says OTC test kits are paid for by Original 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the OTC 
COVID-19 test kit is an OTC item. The Plan does not offer a supplemental benefit covering this service. 
However, these could be obtained with participating providers and covered by Original Medicare when using 
your Medicare card rather than your Plan card. Therefore, we decided that the Plan does not have to pay for the 
over-the-counter (OTC) COVID-19 test kit (K1034) provided on February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on January 30, 2023. 
 
You asked the Plan to waive the copayment for office visit. You say that you feel as though the services should 
be covered because you would like the copayment to be waived.. 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 office visits. 
 
You have been asked to pay a $45 copayment for office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for office visit provided on January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on January 23, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. 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 nursing facility visit 
provided on January 23, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services.  
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were taken from the 
hospital to the rehab center in an ambulance. You were not consulted on this, and you were not given another 
option for transport. The Plan denied your request. The Plan says you were charged this cost sharing 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 $290 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $289.01 for these 
services, which is less than the $290 copayment. 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 ambulance services.