Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have waive the $215.38 deductible applied to the physician services received 
February 9, 2022, and February 22, 2022. 
 
You asked the Plan waive the $215.38 deductible applied to services received February 9, 2022, and February 
22, 2022. You say that you should not have to pay this amount because the services were rendered by an in-
network provider. The Plan denied your request. The Plan says your deductible had not been met at the time 
these claims were processed. 
 
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 there is a $1000 deductible which applies to these services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
Services, Including Doctors Office Visits benefit category in the Medical Benefits Chart. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies to 
physician/practitioner services. This cost sharing is a contractual obligation that had not been met at the time 
these claims were processed. Therefore, we decided that the Plan does not have waive the $215.38 deductible 
applied to the physician services received February 9, 2022, and February 22, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments and deductible for emergency room (ER) 
visits, a specialist office visit, primary care (PCP) visits, X-rays, and magnetic resonance imaging (MRI's) 
provided from January 5, 2022, to April 5, 2022. 
 
You asked the Plan to waive the copayments and deductible for the ER visits, specialist visit, PCP visits, X-
rays, and MRI's. You say that you feel the costs should be waived due to your COVID-19 diagnosis. The Plan 
denied your request. The Plan says the correct copayments and deductible were applied. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan clearly says that you must pay a $50 copayment for each emergency room visit. 
 
Your contract with the Plan also clearly says that you must pay a $35 copayment for each specialist visit and a 
$25 copayment for each PCP visit. 
 
Your contract with the Plan also clearly says that there is $400 deductible which applies to certain items and 
services.  
 
Service Allowed Amount Copayment/Deductible 
ER Visit  January 5, 2022 $130.09 $50.00 (C) 
ER Visit  January 20, 2022 $517.11 $50.00 (C) 
X-rays  February 2, 2022 $10.93 $10.93 (D) 
Specialist Visit  January 24, 2022 $88.00 $35.00 (C) 
X-rays  February 2, 2022 $79.53 $79.53 (D) 
PCP Visit  February 2, 2022 $101.47 $25.00 (C) 
MRI  February 12, 2022 $73.99 $73.99 (D) 
MRI  February 12, 2022 $227.88 $110.55 (D)* 
PCP Visit  March 2, 2022 $151.47 $25.00 (C) 
PCP Visit  April 5, 2022 $101.47 $25.00 (C) 
Total:  $485.00 
 
* Note  Deductible met with this service. 
 
You have been asked to pay a total of $485.00 for the ER visits, specialist visit, PCP visits, X-rays, and MRIs. 
Please note that cost share waivers for COVID-19 ended September 2021. The ER visits fall within the 
Emergency Care benefit category. The specialist and PCP visits fall within the Physician/Practitioner Services, 
Including Doctor's Office Visits benefit category. The X-rays and MRIs fall within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $400 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the X-rays and MRI's were receive. 
Therefore, we decided that the Plan does not have to waive the copayments and deductible for emergency room 
(ER) visits, a specialist office visit, primary care (PCP) visits, X-rays, and magnetic resonance imaging (MRI's) 
provided from January 5, 2022, to April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment without transport (A0998) 
provided on March 29, 2022. 
 
You asked the Plan to pay for ambulance response without transport. You say that you should not be 
responsible for this cost, as you did not call for the ambulance. The Plan denied your request. The Plan says the 
ambulance benefit is a transportation benefit. When no transportation is provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 29, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment without 
transport (A0998) provided on March 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on February 7, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. The Plan 
denied your request. The Plan says this service requires authorization and there is not one on file. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance 
transportation and ground mileage. Our reviewer says that the documentation does not support that the 
ambulance transport on February 7, 2022 was medically reasonable and necessary. Our physician reviewer 
found the documentation does not support that other means of transport (such as stretcher van, wheelchair van, 
taxi, private car, or other type of vehicle) were contraindicated for this enrollee. Our reviewer also found that 
the documentation does not support that the enrollee needed the expertise, services and lifesaving and life-
sustaining equipment that only a fully equipped ambulance could provide for safe transport on February 7, 
2022.  
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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on February 7, 2022.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost for occupational therapy. We decided that the Plan does not 
have to reduce the cost for the hip replacement and self-administered drugs.  
 
You asked the Plan to reduce the cost for the hip replacement, occupational therapy, and self-administered 
drugs. You say that the cost of the evaluation was part of the total hip replacement surgery. You say that this 
should not be billed separately from the services that were covered. The Plan says that the claim processed 
correctly. 
 
We decided that the Plan has to reduce the cost for the occupational therapy evaluation.  
 
The Plan says that you must pay the full allowed amount of $143.43 for the occupational therapy evaluation. 
Your contract with the Plan clearly says that you only pay a $40 copayment for occupational therapy services 
at an in-network outpatient hospital. Therefore, we decided that the Plan has to reduce the cost for the 
occupational therapy evaluation from $143.43 to $40.  
 
We also decided that the Plan does not have to reduce the cost for the hip replacement and self-
administered drugs. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for surgery services at an in-network outpatient hospital. In addition, the self-administered drugs 
requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the 
Plan does not have to reduce the cost for the hip replacement and self-administered drugs. 
 
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. 
 
Benefits for the self-administered drugs 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Ilumya. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Stelara before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug. There is no documentation provided indicating that the Plans required drug would likely be less 
effective and/or likely have adverse effects 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110), manual therapy techniques 
(97140), and the electrical stimulation (G0283) rendered by the out-of-network (OON) provider on May 7, 
2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the therapeutic exercises (97110), manual therapy techniques (97140), and the 
electrical stimulation (G0283) rendered by the out-of-network (OON) provider on May 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with a replacement socket, 
computerized knee, and alignable system for the enrollee. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request for a replacement prosthesis with MPK K3 functional level KNEE 
components does not meet Medicare criteria as being reasonable and necessary. 
 
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 items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is a K3 level ambulator who has a K3 level knee. The health plan has authorized a new 
socket for the prosthesis, but the knee is under warranty. The documentation doesn't support the need for a new 
knee or alignable system. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a prosthetic leg with a replacement socket, computerized knee, and alignable system for the 
enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on November 24, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an x-ray. You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior 
to an out-of-network visit. 
 
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 had network providers 
available who could have provided 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 an x-ray provided on 
November 24, 2021, by an out-of-network (OON) provider.
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 these orthotic devices for your feet are 
medically necessary for your condition. 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 pre-approve additional chiropractic visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee has exhausted the chiropractic benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 additional visits. Our reviewer says 
that the requested services are not medically reasonable or necessary. Our physician reviewer found that in this 
case, the record indicates that the enrollee has back pain.  The record provided is insufficient to establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of 
the coverage criteria are not satisfied. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional chiropractic visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an elbow orthosis (L3761) for the left arm provided on April 
7, 2022. 
 
You asked the Plan to pay for an elbow orthosis. You say that the item at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollee's medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the available medical records do not discuss the item at issue. 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 an elbow orthosis (L3761) for the left arm provided on April 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital stay for a total shoulder arthroplasty for 
the enrollee. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to 
undergo this elective procedure. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the requested total shoulder arthroplasty is documented to have been supported. 
However, detailed documentation is not evident regarding a significant past and/or current medical history that 
would place this enrollee at increased risk for peri-surgical complications requiring an inpatient stay. 
Therefore, the record does not show that at the time of inpatient admission, the admitting physician reasonable 
expected that the patients necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient hospital stay for a total shoulder arthroplasty for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy sessions provided by a 
participating provider. 
 
You asked the Plan to pre-approve physical therapy sessions. You say that additional PT sessions are medically 
necessary. The Plan denied your request. The Plan says medical criteria for additional PT sessions have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 physical therapy sessions. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the enrollee does not require ongoing professional skilled 
therapy. There has been communication/collaboration with a functional skills review with team members and 
treatment results were communicated to interdisciplinary team. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy sessions have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional physical therapy sessions provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for non-routine ophthalmological services 
provided on August 17, 2021. 
 
You asked the Plan to waive the copayment for ophthalmological services. You say that the services at issue 
were a necessity for your care. 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 $40 
copayment for each Medicare-covered eye exam service.  
 
You have been asked to pay a $31.09 copayment for ophthalmological services. Ophthalmological services fall 
within the Vision Care benefit category. This means that you have been asked to pay less than or equal to 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 non-routine ophthalmological services provided on August 17, 2021.