Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received 
from April 8, 2020, to April 13, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you cannot afford 
this copayment but you can pay $5 monthly towards the bill. 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 $325 
copayment per day for days 1-6 for inpatient hospital care.  
 
Records show that you were in the hospital for four days. According to your contract, you pay a $325 
copayment per day for days 1-6 for inpatient hospital care. Therefore, the total amount you have been requested 
to pay for your hospitalization is $1300 ($325 x 4 = $1300.) 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 inpatient hospital services you received from April 8, 2020, to April 13, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you shouldn't have been 
discharged. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $110 
copayment for emergency care.  
 
You have been asked to pay a $110 copayment for an emergency room visit. An 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 waive the copayment for an 
emergency room visit provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the specialist services to be provided by an out of 
network (OON) provider at the in-network rate. 
 
You asked the Plan to pre-approve the specialist services. You say that you would like to see the out-of-
network physician. The Plan denied your request. The Plan says there are network providers available that can 
provide services and the out-of-network physician at issue has not agreed to the plan's terms of coverage. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. Enrollees who 
choose to use out-of-network providers must pay a higher cost-share. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the specialist services to be provided by an out of network (OON) provider at the in-network rate.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis 
(74177) performed. 
 
You asked the Plan to waive the copayment for a CT scan of the abdomen and pelvis. You say that a 
representative of the Plan told you that the Plan would cover your test including the copayment. The Plan 
denied your request. The Plan says the correct copayment was applied. 
 
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 Medicare-covered diagnostic and nuclear medicine radiological services.  
 
You have been asked to pay a $150 copayment for a CT scan of the abdomen and pelvis. A CT scan of the 
abdomen and pelvis 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 a CT scan of the abdomen and pelvis (74177) 
performed.  
 
Your complaint about receiving erroneous or misleading information regarding cost-sharing from a 
representative of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance 
that must be answered by the Plan. Medicare does not permit us to make a decision about these types of 
complaints.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided. 
 
You asked the Plan to pay for the nurse practitioner services. 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 nurse practitioner services provided.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you believe there is a 
coding error on this bill. 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 $240 
copayment for ambulance services.  
 
You have been asked to pay a $240 copayment for the ambulance 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 ambulance services you received.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the massage therapy you received. 
 
You asked the Plan to pay for the massage therapy. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for the massage therapy you received.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a PET scan provided to the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this should be paid for. The Plan denied your request. 
The Plan says that the diagnosis is inconsistent with the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 scan. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
request for the scan was appropriate to guide biopsy if found necessary in a patient with lymphadenopathy. If 
one or more nodes would have been intensely active on PET guided biopsy of that node would be the 
procedure of choice.  So, in interpreting the NCD language for PET imaging the scan was done for a 
recognized reason. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
a PET scan provided to the enrollee.  
 
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. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 documentation does not support that you require services at the LTACH that are 
not available at the acute care hospital where you are currently receiving care. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition at 
this time. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital admission. 
 
You asked the Plan to waive the copayment for an inpatient hospital admission. You say that are being assessed 
a copayment for inpatient care you did not receive. The Plan denied your request. The Plan says the correct 
copayment was applied. 
 
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 admission for a medically necessary inpatient stay.  
 
You have been asked to pay a $50 copayment for an inpatient hospital admission. The case record documents 
an inpatient admission. An inpatient hospital admission 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 admission.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that you need to stay admitted in the SNF as your 
health is in danger. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that you 
require skilled nursing or skilled therapy services, i.e., the specialized skill, knowledge and judgment of a 
skilled professional nurse or qualified therapist is not required to safely and effectively provide medically 
necessary and reasonable treatment beyond 10/27/2020. Based on the medical records provided, you do not 
require the services on an inpatient basis, in a skilled nursing facility setting beyond 10/27/2020. Services in a 
long-term care facility on a part time basis appear 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99204) provided by an out 
of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that prior authorization is not required for telemedicine. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out of network provider. 
 
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 office outpatient visit (99204) provided by an 
out of network (OON) provider.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services provided on March 10, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the services provided were medically 
necessary The Plan denied your request. The Plan says that the services could have been provided in-network. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred to provide the ambulance services by a contract provider. The file does not show that the 
Plan provided notice that the ambulance services would not be covered prior to the services being rendered. 
Under Medicare rules, this means the ambulance services is considered approved by the Plan. Therefore, we 
decided that the Plan has to pay for ambulance services provided on 
March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
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 
physician?s services. 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 physician's services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general care management (G0511) provided, by an
 out of network (OON) provider. 
 
You asked the Plan to pay for the general care management. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 general care management (G0511) provided,
 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided. 
 
You asked the Plan to pay for the office 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 an office visit provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walking cane for a blind person. 
 
You asked the Plan to pre-approve the cane. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is not legally blind. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walking cane for a blind person.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that bisphosphonates are contraindicated. The Plan denied 
your request. The Plan says the enrollee has not failed both oral and intravenous bisphosphonates. 
 
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 Prolia. Our reviewer says that the 
requested Prolia is not shown to be medically necessary. Our physician reviewer found there is no clear 
documentation of the reason for not using first line drugs to include oral and IV bispohosphonates. More 
documentation is needed to justify the use of Prolia at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for a COVID-19 antibody test provided. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says this 
provider has opted out of Medicare and the services are not emergent or urgent. 
 
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 
physician's services for a COVID-19 antibody test provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan of the thorax (71260) performed. 
 
You asked the Plan to waive the copayment for a CT scan of the thorax. You say that you had already reached 
the out-of-pocket maximum. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 Medicare-covered diagnostic radiology services. Your contract also says that the most you will 
have to pay out-of-pocket for in-network covered plan services in 2020 is $2,100. 
 
You have been asked to pay a $150 copayment for a CT scan of the thorax. A CT scan of the thorax falls 
within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The case record 
shows that you reached your out-of-pocket maximum for 2020 with a subsequently processed claim for a 
physician office visit,. This means that you have been asked to pay the correct amount 
for a CT scan of the thorax 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 CT scan of the thorax (71260) performed.