Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the deductible and coinsurance for physical therapy 
(PT) services provided from January 17, 2022, to February 23, 2022. 
 
You asked the Plan to waive or reduce the deductible and coinsurance for the PT services. You say that you are 
unsure of your payment responsibility. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $500 deductible which applies to certain items and services.  
 
Your contract with the Plan also clearly says that you must pay a 4% coinsurance outpatient rehabilitation 
services. 
 
The PT services fall within the outpatient rehabilitation services benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is $500 deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not been met at the time the PT services were 
received from January 17, 2022, to February 23, 2022.  
 
The file shows that at the time the claims were processed, you had $356.86 remaining to meet your deductible. 
The allowed amounts for each claim were applied to this total first. The remaining amount for the January 17, 
2022, date of service is $73.50, and the 4% coinsurance applied is $2.94. The total for all services is $359.80. 
Therefore, we decided that the Plan does not have to waive or reduce the deductible and coinsurance for 
physical therapy (PT) services provided from January 17, 2022, to February 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the air ambulance services provided on 
March 23, 2022. 
 
You asked the Plan to waive the copayment for the air ambulance services. You say that the enrollee was 
bedridden and medical issues required that the enrollee be transported to an inpatient facility by ambulance. 
The Plan denied your request. The Plan says you were charged this cost sharing 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 $50 
copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $50 for these 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 the air ambulance services provided on  
March 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has rehab needs to improve strength, 
endurance and mobility as well as medical needs. The Plan denied your request. The Plan says the requested 
services are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on April 
11, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you feel you should not 
have to pay the copayment for an emergency room visit. You say that your concerns were not addressed and 
you were dissatified with the services received from the provider. The Plan denied your request. The Plan says 
this cost sharing was charged 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 $75 
copayment for emergency care. 
 
You have been asked to pay a $75 copayment for an emergency room visit. This item/service 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 on April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint neurostimulator. 
 
You asked the Plan to pre-approve a Sprint neurostimulator. You say that the requested Sprint neurostimulator 
to treat knee pain is medically necessary. The Plan denied your request. The Plan says the requested Sprint 
neurostimulator to treat knee pain is not medically 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 a Sprint neurostimulator. Our reviewer 
says that the requested Sprint neurostimulator to treat knee pain is not medically necessary. Our physician 
reviewer found the use of a peripheral nerve stimulator is experimental/investigational for knee pain. The 
procedure is not medically reasonable or necessary. 
 
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 Sprint neurostimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Sprint neurostimulator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
February 16, 2022, to March 1, 2022. 
 
You asked the Plan to waive the copayment for hospital care. You say that you were never asked whether the 
enrollee wanted a private room or semi-private room. The Plan denied your request. The Plan says this cost 
sharing was charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $298 copayment for inpatient care per day, days 1 to 5. This inpatient hospital stay lasted 5 days, 
resulting in a copayment of $1,490 ($298 per day for 5 days = $1,490). 
 
The enrollee has been asked to pay $298 copayment per day for hospital care. This item/service falls within the 
inpatient care, days 1 to 5 benefit category. This means that the enrollee has been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for inpatient hospital care provided on February 16, 2022, to March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on July 14, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $35 
copayment for specialist office visits. 
 
You have been asked to pay a $35 copayment for specialist office visit. This item/service falls within the 
specialist 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 waive the copayment for specialist 
office visit provided on July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy 
fields. 
 
You asked the Plan to pre-approve radiation therapy guidance. You say that this guidance is medically 
necessary. The Plan denied your request. The Plan says there is no good evidence that this is a prudent or 
medically effective maneuver. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of ultrasonic guidance for placement of 
radiation therapy fields. have been met. No supporting medical records were submitted for review. The Plan 
requested supporting records, but none were provided to them. Without medical records, we cannot determine 
whether the requested procedure is medically reasonable and necessary for the enrollee. Therefore, we decided 
that the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy fields.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9348 billed for date of service January 2, 
2022, to January 7, 2022. 
 
You asked the Plan to pay for procedure code S9348. You say that the code is payable. The Plan denied your 
request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9348 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9348 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9348 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9348 billed for date of service January 2, 2022, to January 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for fluoroscopic guidance for needle placement 
(77002) provided on April 6, 2022. 
 
You asked the Plan to waive the copayment for fluoroscopic guidance for needle placement. You say that you 
want the Plan to waive the copayment for the service. The Plan denied your request. The Plan says this cost 
sharing was charged 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 an $85 
copayment for Medicare covered radiological diagnostic services.  
 
   
You have been asked to pay a $82.72 copayment for fluoroscopic guidance for needle placement. The service 
at issue falls within the Medicare covered radiological diagnostic services category. Since the allowed amount 
for this service is less than the required copayment of $85, you have been asked to pay only $82.72. 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 fluoroscopic guidance for needle placement (77002) provided on 
April 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is meeting the medical needs as well as 
therapy needs, and it would optimize their level of functioning so they could go home. The Plan denied your 
request. The Plan says the criteria for admission to the Acute Inpatient Rehabilitation setting have not been 
met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy supplies and services provided May 
27, 2022, to June 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for home infusion therapy supplies and services home infusion therapy supplies and 
services. You say that it was necessary to render these services. The Plan denied your request. The Plan says 
the enrollee must get care from network providers. 
 
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 home infusion therapy supplies and services 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 home infusion therapy 
supplies and services these items/services. Therefore, we decided that the Plan does not have to pay for home 
infusion therapy supplies and services provided May 27, 2022, to June 2, 2022, by an out-of-network (OON) 
provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from November 1, 
2021, to April 1, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that you were not told about the charges 
until after you were discharged. The Plan denied your request. The Plan says this cost sharing was charged 
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 $188 
copayment per day for days 21 through 100. 
 
 You have been asked to pay a total of $1,504 copayment for SNF care. This item/service 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 
SNF care provided from November 1, 2021, to April 1, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for an office visit on June 22, 2022. 
 
You asked the Plan to waive the coinsurance for an office visit. You say that you should not be responsible to 
pay this. The Plan denied your request. The Plan says that the cost share was applied correctly. 
 
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. Specifically, the Plan did not include medical records in the original case file. As 
a result, we are unable to verify the services provided or if the correct cost share was applied. Therefore, we 
decided that the Plan has to waive the coinsurance for an office visit on June 22, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ketamine infusion. 
 
You asked the Plan to pre-approve Ketamine infusion. You say that Ketamine infusion is medically necessary. 
The Plan denied your request. The Plan says the request for Ketamine infusion for the enrollee's condition is 
experimental and not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Ketamine infusion have been met. In 
this case, the file shows that the Plan made multiple attempts to obtain medical records for review from your 
doctor with no response. Without these records, we are unable to make a determination based on Medicare 
criteria. Therefore, we decided that the Plan does not have to pre-approve Ketamine infusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this provider regularly complies with all 
administrative requirements for payments. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan. The Plan also says that these services were not approved in advance. 
 
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 office visit provided on July 20, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the in-ear binaural hearing aids (V5130) provided on June 
11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that these hearing aids have been paid for in full, and 
you would like to be reimbursed. The Plan denied your request. The Plan says the non-contracted provider you 
obtained the service from is outside of the Plan's hearing network of providers, and prior authorization was not 
obtained. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use a doctor in the Plan's hearing network. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the in-ear binaural hearing aids (V5130) provided on June 11, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic colonoscopy provided on May 
17, 2022. 
 
You asked the Plan to waive the copayment for diagnostic colonoscopy. You say that you thought this was 
covered in full. The Plan denied your request. The Plan says this cost sharing was charged 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 $275 
copayment for Outpatient hospital visits. 
 
You have been asked to pay a $275 copayment for diagnostic colonoscopy. This item/service falls within the 
Outpatient hospital 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 waive the copayment for diagnostic 
colonoscopy provided on May 17, 2022.