Persius/hicric huggingface dataset:
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 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. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 based on the medical records provided there is concern that the enrollee would not be
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate 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 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: ER
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the emergency room visit provided on
January 25, 2020.
You asked the Plan to reduce the copayment for the emergency room visit. You say that your copayment
should be lowered because you tried to go to go urgent care facilities. You say you had no choice but to go to
the emergency room. The Plan denied your request. The Plan says you have been charged the correct cost
sharing amount.
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 each covered in-network and out-of-network emergency room visit.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the
emergency room visit provided on January 25, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on December 13,
2019.
You asked the Plan to waive the copayment for the ER visit. You say that sometimes you are not charged the
full amount for diagnostic services. You say that you don't understand why the cost is so high. The Plan denied
your request. The Plan says the copayment applied 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 emergency care.
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care"
benefit category. The records show that you received services in the ER. 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 ER visit provided on December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation therapy provided from January 2,
2020 to January 22, 2020.
You asked the Plan to waive the copayment for radiation therapy. You say that you were not informed of the
charges ahead of time. The Plan denied your request. The Plan says the claims were processed correctly and
you are being charged the correct amount.
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 $50
copayment for each radiation therapy service.
You received radiation therapy from January 2, 2020 to January 22, 2020 for a total of 15 services. Therefore,
the total amount you owe is: $50 (copayment) x 15 (radiation therapy services) = $750.
You have been asked to pay the total copayment amount of $750 for radiation therapy. Radiation therapy 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 radiation therapy provided from January 2, 2020 to January 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Low Dose Computed Tomography (LDCT) Lung Cancer
Screening (G0297) provided on April 17, 2019.
You asked the Plan to pay for The LDCT Lung Cancer Screening. You say that the services were medically
necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There
were network providers available.
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the Low Dose Computed Tomography (LDCT) Lung Cancer Screening (G0297)
provided on April 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs (Atorvastatin, Lorazepam,
Metoprolol Tartrate, Omeprazole, Potassium Chloride, Pradaxa, Sacubitril/Valsartan, Hydralazine, and
Tamsolosin) provided on February 18, 2020 and February 19, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you do not feel that you should be held
responsible for these charges. You also say that you were in the hospital at the time these drugs were
administered. The Plan denied your request. The Plan says these drugs are self-administered and are not Part B
covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
(Atorvastatin, Lorazepam, Metoprolol Tartrate, Omeprazole, Potassium Chloride, Pradaxa,
Sacubitril/Valsartan, Hydralazine, and Tamsolosin) provided on February 18, 2020 and February 19, 2020.
Benefits for the self-administered drugs (Atorvastatin, Lorazepam, Metoprolol Tartrate, Omeprazole,
Potassium Chloride, Pradaxa, Sacubitril/Valsartan, Hydralazine, and Tamsolosin) 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the shoulder
(73221).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied
your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the
MRI is not medically necessary. Our physician reviewer found there is no documentation of attempted
conservative care (including medical therapy, physical therapy or a home exercise program). Standard of care
in this scenario is attempted conservative treatment prior to advanced imaging.
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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve Magnetic Resonance Imaging (MRI) of the shoulder (73221).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Geri chair.
You asked the Plan to pre-approve a Geri chair. You say that the enrollee needs a Geri chair for comfort. The
Plan denied your request. The Plan says the enrollee received a standard manual wheelchair in 2019 and there
is no indication that it is in disrepair or not meeting mobility needs.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that the enrollee has a standard manual wheelchair. The standard manual wheelchair serves the
same purpose as a Geri chair. Therefore, we decided that the Plan does not have to pre-approve a Geri chair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the provided medical records do not indicate a
need for inpatient services. Care in the home or an assisted living facility with home health services appears to
be appropriate.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on March 9, 2020.
You asked the Plan to pay for lab test. You say that you only perform this test in your hospital lab. The Plan
denied your request. The Plan says the denial of payment for this service is correct, because this test is not
covered for the diagnosis listed and was not related to a medical diagnosis of disease for the health of the
enrollee.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient
information to determine whether payment is due for a claim. Medicare rules say that a physician order or clear
intent to order specific lab services is required for covered lab services.
We looked at the file and Medicare rules. No lab order or medical records were submitted to the Plan. The Plan
requested this information, but it was not provided. Without these records, you have not submitted sufficient
information to the Plan to determine that payment is due for this claim as billed. Based on this information, we
decided that Medicare rules for coverage of lab test have not been met. Therefore, we decided that the Plan
does not have to pay for laboratory testing provided on March 9, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography (93306) and vascular study (93978)
provided on January 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an OON echocardiography and vascular study. You say that these services were
medically necessary. The Plan denied your request. The Plan says these services were not authorized.
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 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. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the echocardiography (93306) and vascular study
(93978) provided on January 23, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on
November 1, 2019.
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the
orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services
have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis and
suspension sleeve provided on November 1, 2019.
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 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. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 based on the medical records provided there is concern that you would not be able to
fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient
rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring
System.
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee needs a continuous
glucose monitor. The Plan denied your request. The Plan says the enrollee is not on insulin.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The records show the enrollee is not on insulin. Based on this
information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.
Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose
Monitoring System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the knee scooter purchased on January 4, 2020.
You asked the Plan to reimburse you for the knee scooter. You say that the online provider was less expensive than the in-network provider. The Plan denied your request. The Plan says you obtained durable medical equipment from a provider who does not participate with Medicare and the prescription was written after the date of service.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. Durable medical equipment purchased privately through the internet, or by private purchase are not eligible for coverage by your Medicare governed health plan. Medicare does not cover knee scooters. Therefore, we decided that the Plan does not have to reimburse you for the knee scooter purchased on January 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on February 22, 2020.
You asked the Plan to pay for lab test. You say that you only perform this test in your hospital lab. The Plan
denied your request. The Plan says the denial of payment for this service is correct, because this test is
excluded from coverage.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient
information to determine whether payment is due for a claim. The rules say that a physician order or clear
intent to order specific lab services is required for covered lab services.
We looked at the file and Medicare rules. No lab order or medical records were submitted to the Plan. The Plan
asked for supporting records, but they were not provided. Without this information, you have not furnished
sufficient information to justify payment of this claim. Based on this information, we decided that Medicare
rules for coverage of lab test have not been met. Therefore, we decided that the Plan does not have to pay for
laboratory testing provided on February 22, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper GI endoscopy provided on
August 27, 2019.
You asked the Plan to waive the copayment for the upper GI endoscopy. You say that you were told by the
Plan that this service would be paid for. The Plan denied your request. The Plan says you have been charged
the correct cost sharing amount.
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 covered surgery performed at an in-network ambulatory surgical center.
You have been asked to pay a $250 copayment for the upper GI endoscopy. The upper GI endoscopy falls
within the "Outpatient surgery, including services 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. Therefore, we decided that the Plan does not have to waive the copayment for the upper GI endoscopy
provided on August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic image provided on January
22, 2020.
You asked the Plan to pay for the 2D oral/facial photographic image. You say that you believe this claim was
processed incorrectly. The Plan denied your request. The Plan says this service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D
oral/facial photographic image provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 14, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 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. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on September 14,
2019 by an out of network (OON) provider.