Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because these 
inserts are necessary to prevent foot surgery. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you had on 
June 11, 2020. 
 
You asked the Plan to waive the copayment for the EKG. You say that you should not have to pay multiple 
copayments for the same date of service. The Plan denied your request. The Plan says you were charged this 
copayment 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 non-radiological diagnostic services, including EKGs.  
 
You have been asked to pay a $10 copayment for the EKG. The Plan has confirmed that you have not been 
assessed an office visit copayment for this date of service- you were only charged for the EKG copayment and 
the lab copayment (because that service was rendered by a different provider.) 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 electrocardiogram (EKG) you had on June 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you had on June 11, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that these lab services were ordered 
by your doctor during your visit with him.  You stated that you already had to pay a copayment for the office 
visit, so you shouldn't have to pay a separate copayment for the lab. The Plan denied your request. The Plan 
says you were charged this copayment 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 lab services.  
 
You have been asked to pay a $10 copayment for the lab services. Lab services are not included in the costs for 
office visits-- your Health Plan may charge separate copayments for these 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 lab services you had on June 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you had at an outpatient 
hospital facility on July 3, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that the cost of the lab fee should be 
covered in full.  You say that the freestanding lab is very far from your home, which is why you went to an 
outpatient hospital facility for these labs. The Plan denied your request. The Plan says you were charged this 
copayment 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 $40 
copayment for labs provided at an outpatient hospital facility.  
 
You have been asked to pay a $40 copayment for the lab services. This copayment applies regardless of the 
reason why you used an outpatient hospital facility. 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 
lab services you had at an outpatient hospital facility on July 3, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to reduce the cost sharing for the therapeutic phlebotomy services you received at 
an out-of-network outpatient hospital facility on March 18, 2020. 
 
You asked the Plan to reduce the cost sharing for the therapeutic phlebotomy services. You say that you 
shouldn't be charged more because the Plan chose to make all out-of-network services charged at the in-
network rate during the COVID-19 pandemic. The Plan denied your request. The Plan says that 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. Your 
contract with the Plan says that enrollees must pay 40% coinsurance for surgery or other services at an out-of-
network outpatient hospital facility.  
 
The Plan says that a $395 copayment applies to the therapeutic phlebotomy services you had.  The Plan says 
that because the allowed amount ($105.59) is less than your copayment obligation, you are responsible for the 
full amount. We do not agree. Records clearly show that you received these services at an out-of-network 
facility. Based on the Plan contract, you cannot be asked to pay more than 40% coinsurance for the therapeutic 
phlebotomy services at an out-of-network hospital.  This would mean your cost sharing obligation should be 
$42.24 ($105.59 x 40% = $42.24).  It is not appropriate for the Plan to charge you more simply because they 
are choosing to pay for services at the in-network rate during the pandemic. Therefore, we decided that the Plan 
has to reduce the cost sharing for the therapeutic phlebotomy services you received at an out-of-network 
outpatient hospital facility on March 18, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member has no complex medical conditions requiring 
LTACH care. 
 
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. The patient 
appears to be improving and is more stable. He will require ongoing acute care services until the lung 
transplant which can be completed at the current facility. The patient does not require services at the LTACH 
that they are not already receiving at the current facility. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from July 2, 
2019, to July 25, 2019. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
charges because you had to be readmitted due to a bed not being available at another facility. 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 $150 
copayment for days 1-4 for inpatient hospital care.  
 
You had an inpatient hospital stay from July 2, 2019, to July 25, 2019. Therefore, you are responsible to pay a 
$150 copayment for days 1-4 (July 2, 2019, to July 5, 2019). $150 (copayment) x 4 (inpatient days) = $600. 
 
You have been asked to pay the total copayment amount of $600 for an inpatient hospital stay. An inpatient 
hospital stay 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. Therefore, we decided that the Plan does not have to waive the 
copayment for an inpatient hospital stay from July 2, 2019, to July 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the records do not show that you require 
skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse 
required to safely and effectively provide medically necessary and reasonable treatment in a SNF.  Your 
functional level does not require  skilled therapy services with the specialized skill, knowledge and judgment of 
a qualified therapist  to safely and effectively provide medically necessary and reasonable treatment in a SNF.  
 
You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily 
basis" in a SNF. Medicare coverage criteria are not met. 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 services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) 
services.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past 
medical history of atherosclerotic cardiovascular disease, diabetes, sleep apnea, hypertension and carotid artery 
disease who was admitted to an acute hospital on 10/22/2020 for elective coronary artery bypass grafting x 4. 
He underwent surgery and was treated in the hospital for post-operative fluid overload and an ileus; these 
conditions improved with treatment. He required a colonoscopy to decompress the bowel. He was treated for 
urinary retention with a Foley catheter and tamsulosin. He is weak and deconditioned and is working with 
physical and occupational therapy. He is walking 125 feet with contact guard assistance and is minimal assist 
for transfers and activities of daily living. His therapy has been limited by shortness of breath, increased 
respiratory rate and a need for "prolonged seated breaks." He is reported to be medically stable for discharge. 
 
Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
 
The enrollee does require physical therapy and occupational therapy services but based on the medical records 
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern 
that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation facility. 
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve admission to a long term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says that care can be safely received in another setting. 
 
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 considered medically reasonable and necessary in this case. Our physician 
reviewer found you have a long complicated medical history including recent GI bleed, respiratory failure 
requiring tracheostomy and renal failure. Your medical records indicate that you will likely need to be on and 
off a respirator in the coming weeks and need special nursing to assess his respiratory status on a regular basis. 
You also need to be seen by a physician daily to assure stability of your chronic active medical conditions. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve admission to a long term acute care hospital (LTACH).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) with 
a stabilizer (L2385) provided to the enrollee on March 31, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery and relevant medical records which support medical 
necessity for the supplies provided in this case. The documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. 
Therefore the billed code cannot be verified.  The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a 
knee orthosis with suspension sleeve (L1851, L2397) with a stabilizer (L2385) provided to the enrollee on 
March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 24, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges 
because the provider made your ears bleed and charged you a second copayment to treat it. 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 $35 
copayment for each specialist visit.  
 
You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's 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 a specialist visit provided on August 24, 2020.  
 
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit 
the Qualified Independent Contractor (QIC) to make a decision on this type of complaint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on July 18, 2020. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the charges because you 
could not use the device and feel bamboozled by the company. 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 20% 
coinsurance for DME and related supplies.  
 
The medical records show that you received DME on July 18, 2020. Therefore, you are responsible to pay you 
your share of the cost-sharing charges. The allowed amount is $325.53 and 20% of that is $65.11.  
 
You have been asked to pay the total coinsurance amount of $65.11 for DME. DME falls within the DME and 
related 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 coinsurance for DME provided on July 
18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair car ramp. 
 
You asked the Plan to pre-approve a wheelchair car ramp. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a wheelchair car ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Jazzy Air power mobility device (K0899). 
 
You asked the Plan to pre-approve a Jazzy Air power mobility device. You say that this is necessary to prevent 
falls and injuries. The Plan denied your request. The Plan says this type of power mobility device is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power operated vehicle or power wheelchair 
which has not been reviewed by the Pricing, Data Analysis, and Coding (PDAC) contractor or which has been 
reviewed by the PDAC and found not to meet the definition of a specific POV/PWC will be denied as not 
reasonable and necessary and should be coded as K0899. 
 
We looked at the file and Medicare rules. The requested device has not been reviewed by the PDAC contractor 
and found to meet the definition of a specific POV/PWC. Based on this information, we decided that Medicare 
rules for coverage of a Jazzy Air power mobility device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Jazzy Air power mobility device (K0899).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.