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

We decided that the Plan does not have to waive the copayment for the ambulance services you received on 
October 5, 2019. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not have to 
pay this copayment because it wasn't your choice to transfer to a different facility.  You say that the facility 
should pay for this. 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 $250 
copayment per one-way trip for ambulance services.  
 
You have been asked to pay a $250 copayment per one-way trip for the ambulance services. This copayment 
applies regardless of the reason for the transport. 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 you received on October 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had on March 3, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you don't understand why you are 
being charged an office visit when you received an annual wellness visit. The Plan denied your request. The 
Plan says you were not assessed a copayment for the annual wellness services portion of this claim.  However, 
the plan says that you received services from your doctor in addition to the annual wellness visit services. That 
is why you are being charged this copayment. 
 
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 services obtained from a primary care provider.  
 
You have been asked to pay a $10 copayment for the office visit. We looked at the records and found that in 
addition to the annual wellness services, your doctor also performed an electrocardiogram and an evaluation 
and management service.  Since these services are not part of the annual wellness visit, a copayment can apply. 
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 you had on March 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on April 8, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z code identifier should be put next to the code in the 
comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on April 8, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the virtual pacemaker check you had on April 28, 
2020. 
 
You asked the Plan to waive the copayment for the virtual pacemaker check. You say that you didn't see this 
doctor so you shouldn't have to pay this copayment. The Plan denied your request. The Plan says that you were 
charged this copayment 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 a $20 copayment for medical care furnished in a physician's 
office.  In this case, you had a virtual pacemaker check you were not physically present in a physician's 
office for this service. Although there are certain categories of telehealth services for which physician 
copayments are applicable, virtual pacemaker checks are not listed among those services in your Evidence of 
Coverage. It would not be reasonable for the Plan to expect you to know that an office visit copayment would 
apply to this type of remote service without it explicitly being disclosed in your Evidence of Coverage. 
Therefore, we decided that the Plan has to waive the copayment for the virtual pacemaker check you had on 
April 28, 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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the criteria for an inpatient 
rehabilitation stay. The Plan denied your request. The Plan says the documentation does not support that the 
enrollee meets the requirements for an 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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for 
physical and occupational therapy, but it does not support a need for an intensive rehabilitation therapy 
program. Our physician reviewer also found that there is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two extractions and problem focused limited oral 
evaluation provided on January 27, 2020. 
 
You asked the Plan to pay for the extractions and problem focused limited oral evaluation. You say that your 
dentist recommended you have your wisdom teeth removed. You also say that you contacted several providers 
but were told they were not in-network. The Plan denied your request. The Plan says this treating provider 
opted out of Medicare effective April 1, 2008 to April 1, 2022. 
 
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. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the two extractions and problem focused limited oral evaluation provided on January 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are in a lot of pain, cannot walk, and your leg is 
very sore. The Plan denied your request. The Plan says the documentation does not support that you meet 
criteria for an acute rehabilitation 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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. Our 
physician reviewer also found that there is not a reasonable expectation that you will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like to appeal the decision. The 
Plan denied your request. The Plan says the medical records do not support the medical necessity required to 
approve the SNF admission. 
 
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 the SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-
approve the SNF admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would greatly benefit from 
care that can be provided at the LTACH level of care. The Plan denied your request. The Plan says a transfer to 
a LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not already available at 
the current facility. Our reviewer found that there are no services at the LTACH that the enrollee requires that 
are not already available and covered at the current facility. Our physician reviewer also found that transfer to a 
lower level of care may be considered once the enrollee is more stable in the near future. 
 
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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Denosumab (Prolia). 
 
You asked the Plan to pre-approve the Prolia. The Plan denied your request. The Plan says the use of Prolia for 
the requested indication is not approved by the FDA and is not supported by certain reference books. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Prolia. Our reviewer says that Prolia 
is not medically reasonable and necessary for the enrollee. Our physician reviewer found the documentation 
does not support that the Prolia is safe and effective for the enrollee. 
 
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 Prolia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Denosumab (Prolia).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hepatitis A and hepatitis B vaccine (90636) and 
administration (90471) 
 
You asked the Plan to pay for a hepatitis A and hepatitis B vaccine and administration. You say that your 
doctor said you needed these immunizations. The Plan denied your request. The Plan says these are not 
covered. 
 
In the absence of injury, direct exposure to illness, or the risk factors listed above, Medicare does not pay for or 
provide a hepatitis A and hepatitis B vaccine and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to a hepatitis A and 
hepatitis B vaccine and administration. The record also does not show that you have any of the above-listed 
risk factors. Therefore, we decided that the Plan does not have to pay for a hepatitis A and hepatitis B vaccine 
(90636) and administration (90471)  
 
Benefits for a hepatitis A and hepatitis B vaccine and administration 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: Favorable

 
We decided that the Plan has to pre-approve a CT scan. 
 
You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says that the requested 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 a CT scan. Our reviewer says that the 
documentation does support that the requested CT scan is medically reasonable or necessary. Our physician 
reviewer found the enrollee had a CT in June of this year showing lung mass and pleural effusion. The enrollee 
has known lung pathology and recommendation has been made for follow up CT scan. Therefore, the enrollee 
meets criteria for the requested CT scan. 
 
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 CT scan have not been met. Therefore, we decided that the Plan has to pre-
approve a CT scan.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the epidural injection provided on May 12, 2020 
and June 30, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that it would be nice if there was a 
lower cost. The Plan denied your request. The Plan says the claims were processed and paid based on your 
plan. 
 
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 $270 
copay for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
The documentation shows that you received a lumbar epidural injection on each date of service at issue. You 
have been asked to pay a $270 copay for each date of service. The services fall within the outpatient surgery, 
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 copay for the epidural injection provided on 
May 12, 2020 and June 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on February 5, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
services 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 a domiciliary, rest home visit provided on 
February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on March 9, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 did not pre-approve the 
services 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 psychotherapy services provided on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the physician office injection services 
provided February 21, 2020 to March 13, 2020. 
 
You asked the Plan to waive the coinsurance for the physician office injection services. You say that you 
request appeal of denial of payments The Plan denied your request. The Plan says the claims processed 
correctly applying $161.90 towards the deductible and applying the 10% coinsurance. 
 
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 the $390 
deductible and 10% coinsurance for administration of drugs at a specialist's office.  
 
You have been asked to pay $272.33 for the physician office, injection services. The physician?s office, 
injection services falls within the Medicare part B 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 coinsurance for the physician office injection services provided February 21, 2020 
to March 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis provided on January 14, 2020. 
 
You asked the Plan to pay for the knee orthosis. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the item rendered was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that knee orthoses are only covered for certain 
indications. 
 
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 the knee orthosis. Our reviewer says that the 
documentation does not support that item rendered was medically reasonable or necessary. Our physician 
reviewer found the enrollee has advanced arthritis in the right knee. There is no documentation of objective 
joint instability. Therefore, the enrollee did not meet criteria for the item rendered. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does 
not have to pay for the knee orthosis provided on January 14, 2020.