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

 
We decided that the Plan does not have to reduce the coinsurance for durable medical equipment provided by a 
non-participating provider on April 2, 2020, to May 2, 2020. 
 
You asked the Plan to reduce the coinsurance for a CPAP machine. You say that you would like this processed 
as in-network. The Plan denied your request. The Plan says the correct coinsurance 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 40% 
coinsurance for durable medical equipment/out-of-network.  
 
You have been asked to pay a 40% coinsurance of the allowed amount for a CPAP machine. The total allowed 
amount is $427.14. The total amount you are being asked to pay is $170.85 ($427.14 x 40% = $170.85). A 
CPAP machine falls within the durable medical equipment/out-of-network 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 coinsurance for durable medical equipment provided by a non-participating 
provider on April 2, 2020, to May 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram you had on 
May 20, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you thought this was 
a screening service that should not have a copayment. 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 basic imaging services.  
 
You have been asked to pay a $40 copayment for the diagnostic mammogram. The medical records clearly 
indicate that your doctor ordered this mammogram as a diagnostic, not screening, test.  Your doctor ordered 
this test due to your history of breast cancer in the left breast.  That is why this is not considered a preventive 
exam.  Because of that, the diagnostic mammogram falls within the basic imaging services 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 diagnostic mammogram you had on May 20, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip, an inpatient hospital 
stay, and a continued skilled nursing stay provided by a participating provider on March 2, 2020, to March 20, 
2020. 
 
You asked the Plan to waive the copayment for an ambulance trip, an inpatient hospital stay and a continued 
skilled nursing stay. You say that your mother was given poor quality of care. 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $200 copayment for ambulance services, a $270 copayment per day for days 1-6 for an inpatient 
hospital stay and a $0 copayment per day for days 1-20 and a $120 copayment per day for days 21-45 for 
skilled nursing facility (SNF) care.  
 
The enrollee has been asked to pay a $200 copayment for an ambulance trip, a $270 copayment per day for 
days 1-3 for an inpatient hospital stay and a $0 copayment per day for days 1-20 and a $120 copayment per day 
for days 21-36 for a skilled nursing stay. 
 
Service Copayment Number of Days Total Amount Owed 
Ambulance $200  $120 
Inpatient Hospital Stay $270 per day (days 1-6) 3 $810 
Skilled Nursing Stay $120 per day (days 21-36) 15 $1,800 
 
Total Amount Owed: $120 + $10 + $1,800 = $2,730. 
 
An ambulance trip falls within the ambulance services benefit category, an inpatient hospital stay falls within 
the inpatient hospital care benefit category and a continued skilled nursing stay falls within the skilled nursing 
facility (SNF) care benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
ambulance trip, an inpatient hospital stay, and a continued skilled nursing stay provided by a participating 
provider on March 2, 2020, to March 20, 2020.  
 
Your quality of care concern has been handled separately by the health plan. Medicare does not permit 
QIC to make a decision on this type of complaint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 15, 2020. 
 
You asked the Plan to pay for the physician's 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 
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 on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve angiography and revascularization procedure of the 
lower extremity for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no evidence in the last note for this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee presents without new complaints after the revascularization procedures of the right 
lower extremity. It is documented that his claudication symptoms are improved. His feet are equally warm 
bilaterally.  Recent notes that described the ulcers on the right foot do not describe ulcers on the left. The 
photos are uninterpretable.  At his most recent visits he has not been documented be complaining of rest pain.  
In summary, in the absence of evidence rest pain or tissue loss, or documentation of lifestyle limitation due to 
PAD, there is insufficient evidence in the medical record to overturn the health plan determination. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve angiography and revascularization procedure of the lower extremity for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hearing services and does not have to 
waive the coinsurance for a diagnostic procedure provided on July 7, 2020. 
 
You asked the Plan to waive the copayment for hearing services and to waive the coinsurance for a diagnostic 
procedure. You say that you disagree with the charges because you never received the results. 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 $25 
copayment for hearing services. Your contract with the Plan also clearly says that you must pay 4% 
coinsurance for diagnostic tests. 
 
You received hearing services on July 7, 2020. Therefore, you are responsible to pay the $25 copayment.  
 
You received a diagnostic procedure on July 7, 2020. The allowed amount is $185.77 and 4% of that is $7.43.  
 
The total amount you owe is: $32.43.   
 
You have been asked to pay the total amount of $32.43 for hearing services and a diagnostic procedure. 
 
 
Hearing services fall within the hearing services benefit category. A diagnostic procedure 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 hearing services and does not have to waive the coinsurance for a diagnostic 
procedure provided on July 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure 
(CPAP) device and humidifier (E0562). 
 
You asked the Plan to pre-approve continued use of a CPAP device and humidifier. You say that you would 
like the Plan to reconsider their denial. The Plan denied your request. The Plan says the medical information 
shows you were not adherent to therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that you must use the PAP 4 hours per night on 70% 
of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.  
 
We looked at the file and Medicare rules. The compliance report included with the file indicates you did not 
adhere to therapy. Based on this information, we decided that Medicare rules for coverage of continued use of a 
CPAP device and humidifier have not been met. Therefore, we decided that the Plan does not have to pre-
approve continued use of a continuous positive airway pressure (CPAP) device and humidifier (E0562).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for audiology services provided on June 26, 2020. 
 
You asked the Plan to pay for the audiology 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 audiology services provided on June 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve JAK2 V617F mutation analysis for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is needed to assess whether the enrollee has 
polycythemia vera or a myeloproliferative disorder that is causing elevated blood counts. The Plan denied your 
request. The Plan says the enrollee has not had BCR-ABL testing as required by the guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there was no evidence of a previously negative BCR-ABL which is required prior to considering this 
test. Therefore, based on the provided documentation, this patient does not effectively meet criteria for the 
JAK2 V617F mutation testing 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve JAK2 V617F mutation analysis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of a covered condition for hyperbaric oxygen therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 therapy. Our reviewer says that the 
requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the reviewed documentation indicates that the enrollee does not have an indication for hyperbaric oxygen 
therapy. The requested hyperbaric oxygen therapy is not medically necessary or reasonable. The enrollee does 
not have diabetes mellitus, this is not a diabetic wound, also does not have acute CO2 intoxication, 
decompression illness, gas embolism, gas gangrene, acute traumatic peripheral ischemia, crush injury, 
necrotizing fasciitis, acute peripheral arterial insufficiency, skin grafts. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for acupuncture services (97811, 97810) 
provided June 29, 2020. 
 
You asked the Plan to waive the copayment for the acupuncture services. You say that the copayment should 
be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 $15 
copayment for acupuncture services.  
 
You have been asked to pay a $15 copayment for the acupuncture 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 acupuncture services (97811, 97810) provided June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit (99326, 99497) provided on March 9, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for an OON rest home visit. You say that these were medically necessary services 
provided in good faith. 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 rest home visit (99326, 99497) provided on 
March 9, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings. The Plan 
denied your request. The Plan says you do not have a qualifying wound. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services provided by a 
participating provider on June 11, 2020. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you made this appointment 
for your primary care physician. 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 $20 
copayment for urgently needed services.  
 
You have been asked to pay a $20 copayment for urgent care services. The correct copayment has been applied 
to the services were provided. Urgent care services fall within the urgently needed services 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 urgent care services provided by a participating provider on 
June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed services provided on 
January 31, 2020. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the 
charges because the visit was related to COVID-19. 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 $30 
copayment for urgently needed services.  
 
You have been asked to pay a $30 copayment for urgently needed services. Urgently needed services fall 
within the urgently needed services 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 
urgently needed services provided on January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you would like reconsideration because 
the member is bed-ridden and requires these supplies. The Plan denied your request. The Plan says this is not a 
Medicare covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy services (99183). 

You asked the Plan to pre-approve HBO therapy services. You say that HBO therapy would highly increase the 
enrollee's ability to heal his wounds. The Plan denied your request. The Plan says the enrollee has not had an 
adequate course of standard wound therapy. 
 
The Plan follows Medicare rules. Medicare rules say that HBO is covered for chronic refractory osteomyelitis 
that is unresponsive to conventional medical and surgical management. 
 
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 HBO therapy services. Our reviewer 
says that the criteria for coverage of HBO therapy have not been met. Our physician reviewer found the records 
show that the enrollee has osteomyelitis of the left 5th digit related to vascular disease and diabetes. The 5th 
digit was amputated on October 31, 2020, and a procedure to improve blood flow was performed on November 
4, 2020.  This is considered acute osteomyelitis, and additional time is needed to assess whether these measures 
will lead to wound healing.  HBO is indicated when standard wound therapy has failed.  It is reasonable to 
allow an additional 2 to 3 weeks of standard wound care and antibiotics before considering HBO. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve hyperbaric oxygen (HBO) therapy services (99183).