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

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on February 23, 
2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you are on a fixed income so this charge 
should be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $0 
copayment or $175 copayment for Medicare-covered diagnostic radiology services (not including x-rays).  
 
You have been asked to pay $175 copayment for the CT scan. CT scans fall 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 the CT scan provided on February 23, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by an 
out-of-network (OON) facility. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has had physical therapy in your 
hospital in the past. The enrollee has an ankle fracture and needs rehab and cannot be discharged home. The 
Plan denied your request. The Plan says they are not denying the access to care, the Plan is denying services 
with an OON provider at the in-network benefit cost share. The Plan also says the service are available in-
network. 
 
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. 
 
 
 
 
 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 
skilled nursing facility (SNF) care to be provided by an out-of-network (OON) facility.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve testosterone. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. 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 pre-approve testosterone.  
 
Benefits for these services 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  ER services provided from December 20, 
2021, to December 21, 2021.  
 
You asked the Plan to waive the copayment for ER services. You say that you are unable to work due to 
COVID-19 and cannot afford these payments so they should be covered. The Plan denied your request. The 
Plan says the copayment applied is correct. 
 
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 $90 
copayment for Medicare covered emergency room visits.  
 
You have been asked to pay $90 copayment for ER services. ER services fall 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  ER services provided from 
December 20, 2021, to December 21, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an eye exam provided on February 10, 2022. 
 
You asked the Plan to waive the copayment for an eye exam. You say that you should not have to pay this 
copayment. The Plan denied your request. The Plan says that the copayment applied is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The records show a medical eye exam was billed. However, a claim or medical 
records were not submitted to support a medical eye exam was performed. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in 
your favor. Therefore, we decided that the Plan has to waive the copayment for an eye exam provided on 
February 10, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive your $60 copayment mental health services provided on 
January 6, 2022. 
 
You asked the Plan to waive your $60 copayment for mental health services. You say that you were told your 
doctors were In-Network. The Plan denied your request. The Plan says you must pay a $60 copayment for each 
Out-of-Network Medicare covered individual or group therapy visit. The Plan contract also says you must pay 
a $60 copayment for each Out-of-Network Medicare covered individual or group therapy visit with a 
psychiatrist. 
 
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 $60 copayment for Outpatient Mental Health Care.  
 
You have been asked to pay a $60 copayment for mental health services. Mental health services fall within the 
Outpatient Mental Health 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 your $60 copayment 
mental health services provided on January 6, 2022.  
 
Your complaint about being given incorrect information about the network status of the provider 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-
thigh (78815). 
 
You asked the Plan to pre-approve a PET scan. You say that the requested PET scan is medically necessary. 
The Plan denied your request. The Plan says that the requested PET scan does not meet criteria. 
 
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 a PET scan. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollees LCD criteria consider PET scans 
medically necessary if used to determine eligibility of an invasive therapeutic procedure. If the enrollee has 
metastatic disease, the treatment plan would change, without the need for aggressive prostate-directed radiation 
therapy. The CT imaging shows non-specific enlarged lymph nodes, and the bone scan shows no abnormal 
activity. The PSMA PET ordered for the enrollee is considered superior to other PET modalities (FDG, 
Axumin, NaF) in terms of sensitivity and specificity. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) for 
attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on October 
4, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this charge should be 
covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $250 
copayment for each one -way Medicare covered ground trip.  
 
You have been asked to pay $225.14 which is less than the standard $250 copayment for ambulance transport. 
Ambulance transport falls within the Ambulance 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 ambulance transport provided on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound care provided from January 11, 
2022, to March 7, 2022. 
 
You asked the Plan to waive the copayments for wound care. You say that this service was provided at the 
wound clinic so it should only be a $30 copayment. The Plan denied your request. The Plan says the copayment 
applied is correct. 
 
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 $150 
copayment for Medicare-covered outpatient hospital surgery services.  
 
 
 
 
 You have been asked to pay a total of $2684.32 copayment for wound care.  
 
Date of Service Service Allowed Amount Standard 
Copayment 
Member Liability 
January 11, 2022 Wound Care $145.68 $150 $145.68 
January 17, 2022 Wound Care $145.68 $150 $145.68 
January 24, 2022 Wound Care $145.68 $150 $145.68 
January 31, 2022 Wound Care $150.01 $150 $150.00 
February 2, 2022 Wound Care $150.01 $150 $150.00 
February 7, 2022 Wound Care $150.01 $150 $150.00 
February 9, 2022 Wound Care $150.01 $150 $150.00 
February 11, 2022 Wound Care $150.01 $150 $150.00 
February 14, 2022 Wound Care $150.01 $150 $150.00 
February 16, 2022 Wound Care $150.01 $150 $150.00 
February 18, 2022 Wound Care $150.01 $150 $150.00 
February 21, 2022 Wound Care $150.01 $150 $150.00 
February 23, 2022 Wound Care $150.01 $150 $150.00 
February 25, 2022 Wound Care $150.01 $150 $150.00 
February 28,2022 Wound Care $150.01 $150 $150.00 
March 2, 2022 Wound Care $150.01 $150 $150.00 
March 4, 2022 Wound Care $150.01 $150 $150.00 
March 7, 2022 Wound Care $150.01 $150 $147.28 
Total:    $2684.32 
 
Wound care falls within the Outpatient hospital 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 copayments for wound care provided from January 11, 2022, to March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a primary care office visit provided on 
December 8, 2021. 
 
You asked the Plan to reduce the copayment for the office visit. You say that the claim was billed incorrectly. 
The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for each primary care doctor visit.  
 
You have been asked to pay $74.23, which is 20% of the allowed amount for the office visit ($371.14 allowed 
amount x 20% coinsurance = $74.13). The Plan has indicated that they pay the allowable amount regardless of 
what the provider billed, per their contract with that provider. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the copayment for a primary care office visit provided on December 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 2 Sensor, continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve CGM. You say that the requested CGM is medically necessary. The Plan 
denied your request. The Plan says the coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
  
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of CGM have not been met. Therefore, we decided that the Plan does 
not have to pre-approve FreeStyle Libre 2 Sensor, continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Skilled Nursing Facility (SNF) care on July 
24, 2021, to August 01, 2021. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF). You say that the facility did not 
request an extension for the additional stay. The Plan denied your request. The Plan says $20 copayment for 
days 1-20; $0 day(s) 21-100. We cover 100 days per benefit period. A prior hospital stay is not required. A 
benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when 
you havent received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row including your 
day of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new 
benefit period begins. There is no limit to the number of benefit periods. 
 
 
 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 days 1-20 for skilled nursing facility care. There were 31 total days, which would result in a 
copayment amount of $400; however, you have been asked to pay $120 because this amount met the $1,600 
maximum out-of-pocket amount for 2021.    
 
You have been asked to pay a $20 copayment for skilled nursing facility (SNF). Skilled nursing facility (SNF) 
falls within the Skilled Nursing Facility (SNF) 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 Skilled Nursing Facility (SNF) care on July 24, 2021, to August 01, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from November 1, 2020, to November 7, 2020. 
 
You asked the Plan to pay for the services. You say that  The Plan denied your request. The Plan says the 
provider has reported skilled services with the incorrect PDPM Health Insurance Prospective Payment System 
(HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that the denied codes are not supported in the medical record. Specifically, there are some 
discrepancies on how the scores for toilet hygiene. The coding for toilet hygiene differs on the 5 day MDS 
from the provided GG support document. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for skilled 
nursing facility (SNF) services provided to the enrollee from November 1, 2020, to November 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for future specialist office visits. 
 
You asked the Plan to waive the copayments for the future office visits. You say that you will not be able to 
afford the copayments for the enrollee. The Plan denied your request. The Plan says the copayment is a set 
amount and cannot be waived. 
 
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 enrollees contract with the Plan clearly says that enrollees 
must pay a $50 copayment for each visit with a specialist.  
 
The EOC says there is a $50 copayment for each visit with a specialist. The future office visits fall within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. 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 copayments for future specialist office visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for diagnostic swallowing test provided on 
October 19, 2021. 
 
You asked the Plan to waive the deductible for swallowing test. You say that the swallowing test is a lot of 
money, and you should not be charged for this. The Plan denied your request. The plan says your deductible 
had not been met at the time the testing was done. The Plan says the deductible amount was applied 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 there is $750 deductible which applies to basic imaging services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $750 deductible which applies to basic imaging services. This cost 
sharing is a contractual obligation that had not been met at the time swallowing test was received on October 
19, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the diagnostic 
swallowing test provided on October 19, 2021..
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 SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 in the Medicare rules section 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 daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).