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

 
We decided that the Plan does not have to waive the copayment for an endoscopy performed on September 14, 
2021. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that another provider found a hiatal 
hernia. You say that you should not owe for the endoscopy since they did not find it. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for surgical services provided at an outpatient hospital.  
 
You have been asked to pay a $325 copayment for the endoscopy. The endoscopy falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 endoscopy performed on September 14, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four bone replacement grafts (D4263 x4). 
 
You asked the Plan to pre-approve the bone replacement grafts. You say that you understand that is medical 
necessary to prevent premature tooth loss and is part of dental surgery. The Plan denied your request. The Plan 
says the dental service requested for reimbursement is intended to address a dental problem, is not related to 
any medical condition, and is not incidental to or an integral part of a medical service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit.  
 
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve four bone replacement grafts (D4263 x4).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral lumbar radiofrequency ablation for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence that pain relief lasted six months with 50% improvement in 
performing previously painful movements. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation must show that the enrollee has had at least 2 medial branch blocks (MBB) injections 
and that these injections should each show at least 80% pain relief.  In this case, the documentation stated that 
the enrollee had treatment for this type of pain before and that the facts showed that they only anywhere from 
0% to 80% relief of pain for the previous procedures. The enrollee had no consistent pain relief of a minimum 
of 80% sustained relief after previous lumbar MBBs. The enrollee also had several prior RFAs done at the 
same level with documentation showing varied responses to degree of benefit (0-80% for the same procedure) 
and no documentation to support a minimum consistent 50% improvement in pain relief for at least 6 months or at least a minimum of 50% in his ability to perform previously painful movements and ADLs compared to 
baseline. The review has determined that the enrollee does not meet the coverage criteria detailed in 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral lumbar radiofrequency ablation for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you are not able to 
take part in 3 hours of therapy a day. 
 
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 physician reviewer found 
that you were admitted to the hospital for a planned spinal surgery. You have remained medically stable. The 
most recent therapy notes indicate that you are able to ambulate short distances without hands on assistance.  You continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement. However, the documentation does not support that you would meet criteria for admission to an 
acute inpatient rehabilitation facility. There is no indication that you require skilled rehabilitation services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain your 
functional status. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for podiatry visits provided on January 19, 
2022, and January 28, 2022. 
 
You asked the Plan to waive the deductible for the podiatry visits. You say that you were not seen for a 
podiatry issue. You say that you should only have a $35 copayment. The Plan denied your request. The Plan 
says the correct amount was applied to your deductible. 
 
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 certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Podiatry Services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 
deductible which applies to certain items and services. Please note that only routine podiatry services are not 
subject to the deductible. In this case, both visits were for specific conditions.  
 
  
This cost sharing is a contractual obligation that had not been met at the time the podiatry visits were received 
on January 19, 2022, and January 28, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for podiatry visits provided on January 19, 2022, and January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 27, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you did not see the doctor and 
only gave medical history to a staff member. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for each in-person specialist visit.  
 
The record shows that you were seen and evaluated for a follow-up visit on July 27, 2021. Therefore, you have 
been asked to pay a $35 copayment for the office visit. 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 waive the copayment 
for a specialist office visit provided on July 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen. 
 
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 the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have presence of blood in the urine 
(hematuria) and no other complaints. The records do not contain documentation of a full examination of the 
abdomen with abnormal results or follow-up testing for hematuria to support advanced imaging at this time. 
There is no explanation from the treating physician for how the imaging would positively help. The CT scan is 
not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the abdomen.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 22, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the provisions of the test meet Medicare 
coverage and the test was ordered by the treating physician. The Plan denied your request. The Plan says the 
rendering and referring providers are both OON providers and the enrollee's primary care physician did not 
refer for services. 
 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 the laboratory services provided on August 22, 
2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary services provided on January 14, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were not urgent or emergent. 
 
 
 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 Domiciliary services provided on January 14, 
2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit provided on September 
27, 2021. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you were told to return to the 
trauma unit to have your stitches removed. You say that you don't understand why you are receiving a 
copayment for the service. The Plan denied your request. The Plan says you have been charged the correct 
copayment amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for each in-person specialist visit.  
 
 
 
 
 You have been asked to pay a $35 copayment for the specialist visit. The specialist visit falls within 
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 the specialist visit provided on September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Pathology services provided on  January 19, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Pathology services. You say that you are requesting reconsideration stating that 
you did not know that you had to have a referral to have this procedure done. The Plan denied your request. 
The Plan says the provider is out-of-network and it was determined these services were not urgent or emergent. 
 
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 Pathology services provided on  January 19, 
2022 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for radiation therapy provided from 
September 2, 2021, to September 30, 2021.  
 
You asked the Plan to waive the copayments for radiation therapy. You say that the hospital told you that you 
do not have a copayment for their services. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each radiation therapy service.  
 
 
 You have been asked to pay up to a $50 copayment for each radiation therapy service received from September 
2, 2021, to September 30, 2021. Radiation therapy falls within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category.  
 
Date of Service Code Copayment 
September 2, 2021 77332 $15.11 
September 7, 2021 77332 $50 
September 13, 2021 G6016 $50 
September 14, 2021 G6016 $50 
September 15, 2021 G6016 $50 
September 16, 2021 G6016 $50 
September 17, 2021 77336 $50 
September 20, 2021 G6016 $50 
September 21, 2021 G6016 $50 
September 22, 2021 G6016 $50 
September 23, 2021 G6016 $50 
September 24, 2021 77336 $50 
September 27, 2021 G6016 $50 
September 28, 2021 G6016 $50 
September 29, 2021 G6016 $50 
September 30, 2021 G6016 $50 
Total  $765.11 
 
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 radiation therapy provided from September 2, 2021, to 
September 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the enrollee ambulates with a significant 
limp and has severe difficulty negotiating stairs. The Plan denied your request. The Plan says the 8 additional 
PT visits are not medically necessary. 
 
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 additional PT visits. 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 additional requested therapy generally is not accepted as specific 
and effective therapy for the patients condition beyond what was approved by the Plan. Our reviewer found 
that the patient has had prior extensive therapy and the documentation does not reveal that the patient requires 
the unique skills of a professional therapist to safely and effectively provide treatment, that the services can be 
safely and effectively performed only by a therapist, or by or under the supervision of a therapist. Our 
physician reviewer also found that the requested services are not part of a maintenance program, and the 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 8 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Chronic Care Management Services provided on November 
1, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Chronic Care Management Services. You say that that it isn't your responsibility 
to obtain prior authorization. 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 Chronic Care 
Management Services provided on November 1, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve in-home support services. 
 
You asked the Plan to pre-approve in-home support services. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says that they made a determination based on 
incorrect criteria. 
 
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 Plan confirmed they used the incorrect Medicare criteria to confirm their 
reasoning for the denial of the requested services. The Plan has not supported their denial of the requested in-
home services based on their supplemental benefit criteria. Therefore, we decided that the Plan has to pre-
approve in-home support services.  
 
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 reduce the cost share for a dermatology specialist office visit 
provided on July 8, 2021. 
 
You asked the Plan to reduce the cost share for a specialist office visit. You say that your deductible was met at 
the time of the July 8, 2021, visit. You also say that you were told you only had a $5 copayment. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 a specialist office visit.  
 
The record shows the specialist visit was applied to your 2021 deductible. The item or service you asked the 
Plan to reduce the cost share for falls within the Physician/Practitioner Services, Including Doctors Office 
Visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
$500 deductible which applies to a specialist office visit. This cost sharing is a contractual obligation that had 
not been met at the time a specialist office visit was received on July 8, 2021. Therefore, we decided that the 
Plan does not have to reduce the cost share for a dermatology specialist office visit provided on July 8, 2021.