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

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on June 
03, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you went to the ER for 
back pain, and they did nothing for it. Due to this, you feel you should not need to pay the copayment. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 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 June 03, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on June 
19, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were sent to the ER 
by your provider for covid symptoms and feel you should not have this bill. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 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 June 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on February 21, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you were not aware you had a cost-share 
until you received a bill, and you are unable to receive more supplies until the balance is paid. You say that you 
are requesting the cost-share be paid because someone told you DME was 100% 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 20% 
coinsurance for each Medicare-covered durable medical equipment item.  
 
You have been asked to pay a coinsurance of #120.48, which is 20% of the allowed amount for DME ($602.40 
allowed x 20% = $120.48). This item/service falls within the Durable Medical Equipment (DME) and Related 
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 coinsurance for DME provided on 
February 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in-home physical therapy services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy services. You say that there are no in-network 
providers that can provide the services the enrollee needs. The Plan denied your request. The Plan says the 
requested provider is an OON provider and there are in-network providers that can provide the requested 
services that the enrollee needs. 
 
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 
in-home physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary for the enrollee 
to receive LTACH services. The Plan denied your request. The Plan says the Medicare criteria was not met for 
LTACH admission and the enrollee's needs can be met at an inpatient facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a one-month supply allowance (K0553) and therapeutic 
continuous glucose monitor (CGM) receiver (K0554). 
 
You asked the Plan to pre-approve the supply allowance and CGM receiver. You say that your doctor advised 
you need the CGM. The Plan denied your request. The Plan says the documentation does not support that you 
are using 3 or more insulin injections per day, or that your insulin dose is frequently adjusted based on the 
results of your glucose monitor. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
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 assess 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 use insulin 
with at least three daily injections, or 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 the supply 
allowance and CGM receiver have not been met. Therefore, we decided that the Plan does not have to pre-
approve a one-month supply allowance (K0553) and therapeutic continuous glucose monitor (CGM) receiver 
(K0554).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ambulance ride provided on June 23, 
2022. 
 
You asked the Plan to reduce the copayment for an ambulance ride. You say that this should be $100 not $350 
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 $350 
copayment for ambulance services. 
 
You have been asked to pay a $350 copayment for an ambulance ride. This item/service 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 reduce the copayment for an ambulance ride 
provided on June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specilist visit provided on April 29, 2022. 
 
You asked the Plan to waive the copayment for a specilist visit. You say that since you could not see your 
primary care doctor, therefore you feel you should not have to pay more than a prime care copay. 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 $45 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for a specilist visit. This item/service falls within the 
Physician/Practitioner services, including doctors 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 a specilist visit provided on April 29, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapeutic exercises provided on April 27, 
2022, to July 08, 2022. 
 
You asked the Plan to waive the copayment for therapeutic exercises. You say that you were referred by the 
Pulmonologist for therapy to strengthen your lungs. You say that you were told it was covered by the 
insurance. 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 $880 
copayment for outpatient rehabilitation service. 
 
You have been asked to pay a $880 copayment for therapeutic exercises. This item/service falls within the 
outpatient rehabilitation service 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. The copayment is $40 per therapeutic visit and there were 22 visits ($40 x 22 
visits = $880). Therefore, we decided that the Plan does not have to waive the copayment for therapeutic 
exercises provided on April 27, 2022, to July 08, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for myocardial tomographic imaging provided 
on July 13, 2022. 
 
You asked the Plan to waive the copayment for myocardial tomographic imaging. You say that you cannot 
afford this and were not told this copayment would be due. 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 $300 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $300 copayment for myocardial tomographic imaging. This item/service 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 myocardial tomographic imaging provided on July 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided on July 14, 2022. 
 
You asked the Plan to waive the copayment for lab work. You say that you should not oew this copayment. 
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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for lab work. This item/service 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 lab work provided on July 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on April 18, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you feel you should not owe this 
copayment. 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 $85 
copayment for outpatient hospital services. 
 
You have been asked to pay a $85 copayment for an x-ray. This item/service 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 copayment for an x-ray provided on April 
18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service June 28, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76700 billed for date of service June 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that a fixed height hospital bed (E0250, E0251, E0290, 
E0291, and E0328) is covered if specific criteria are met. 
 
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 semi-electric hospital bed. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the semi-electric hospital bed at issue in this case meets all of 
Medicare's Local Coverage Determination (LCD): Hospital Beds and Accessories - L33820 criteria for 
medically reasonable and necessary for the enrollee. Provided records do not document that the enrollee has a 
medical condition which requires positioning of the body in ways not feasible with an ordinary bed, requires 
elevation of the head/upper body less than 30 degrees, requires traction equipment, which can only be attached 
to a hospital bed or requires frequent changes in body position and/or has an immediate need for a change in 
body position as required by the LCD. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SPRINT peripheral nerve stimulators (PNS). 
 
You asked the Plan to pre-approve SPRINT PNS. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that payment may be made under the prosthetic device 
benefit for implanted peripheral nerve stimulators. Use of this stimulator involves implantation of electrodes 
around a selected peripheral nerve. 
 
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 SPRINT PNS. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of the Sprint PNS system for 
thoracic pain would be investigational. The request is deemed 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 SPRINT PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SPRINT peripheral nerve stimulators (PNS).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service is 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, for 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 May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam (92012) provided on June 2, 2022. 
 
You asked the Plan to pay for an eye exam (92012). You say that a colonoscopy is covered if someone has 
diabetes. You also say that you had a detached retina, and believe this should be treated as diabetes. 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 a $300 deductible which applies to Vision Care.  
 
 
  You have been asked to pay $64.16 toward your deductible for an eye exam (92012). The item or service you 
asked the Plan to pay for falls within the Vision Care benefit category. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is a $300 deductible which applies to Vision Care. This cost 
sharing is a contractual obligation that had not been met at the time an eye exam (92012) was received on June 
2, 2022. Therefore, we decided that the Plan does not have to pay for an eye exam (92012) provided on June 2, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve an LDCT scan. The Plan denied your request. The Plan says the request did 
not include any clinical notes. 
 
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 an LDCT scan have been met. 
Additional medical records were not provided for this case. The record shows that the Plan made multiple 
attempts to obtain the additional records, but they were not received. Without this information, we cannot 
determine if the enrollee meets the criteria for coverage for the LDCT scan. Therefore, we decided that the Plan 
does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.