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

 
We decided that the Plan does not have to waive the copayment for telehealth specialist visit provided on April 
4, 2022. 
 
You asked the Plan to waive the copayment for telehealth specialist visit. You say that you didn't discuss 
anything medical over the phone so it 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 $35 
copayment for each specialist telemedicine visit.  
 
You have been asked to pay $35 copayment for telehealth specialist visit. Telehealth specialist visits fall 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 telehealth specialist visit provided on April 4, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy visits provided from 
January 12, 2022, to January 27, 2022. 
 
You asked the Plan to waive the copayments for physical therapy visits. You say that you thought you would 
pay $10 copayment after you finished your physical therapy at home. 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 $10 
copayment for each Medicare covered outpatient rehabilitation service, treatment, or evaluation.  
 
 
 
 You have been asked to pay $50 ($10 x 5 visits) copayment for the physical therapy visits. Physical therapy 
visits fall within the Outpatient rehabilitation 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 physical therapy visits provided from January 12, 2022, to January 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequence testing panel (0037U) provided 
on January 18, 2022. 
 
You asked the Plan to pay for the next generation sequence testing panel. You say that you would like this 
claim reprocessed for medical necessity. The Plan denied your request. The Plan says the provided testing is 
not covered per Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the next generation sequence testing panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the next generation sequence testing panel (0037U) provided on January 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on February 18, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for outpatient surgery. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 outpatient surgery at issue in this appeal. The Plan did not pre-approve 
the outpatient surgery at issue. We found no exception that would require the Plan to pay for the outpatient 
surgery. Therefore, we decided that the Plan does not have to pay for outpatient surgery provided on February 
18, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography procedures provided on February 16, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for echocardiography procedures. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for echocardiography procedures provided on 
February 16, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
January 18, 2022, to January 23, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you had to stay in the 
hospital longer due to having COVID-19 so you feel that the extra days you were there 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 $325 
copayment per days 1 through 6 of your Medicare covered hospital admission/stay.  
 
You have been asked to pay $1,625 ($325 x 5 days) copayment for inpatient hospital stay. Inpatient hospital 
stay falls within the Inpatient hospital 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 inpatient hospital stay provided from January 18, 2022, to January 23, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy office visits provided from December 02, 
2021 to January 11, 2022. 
 
You asked the Plan to pay for psychotherapy office visits. You say that you feel as though the services should 
be covered because you were told you could go to this provider if you obtained a referral from your PCP. The 
Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 psychotherapy office visits provided from 
December 02, 2021 to January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
November 4, 2020 to December 3, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the medical 
records submitted did not contain the Plan of Care for the enrollee. Therefore, we decided that the Plan does 
not have to pay for the home health services provided to the enrollee from November 4, 2020 to December 3, 
2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for transthoracic echocardiography (C8929) 
and radiology/nuclear medicine service (78452) on November 30, 2021. 
 
You asked the Plan to waive the copayment for transthoracic echocardiography (C8929) and radiology/nuclear 
medicine service (78452). You say that you would like to appeal the cost share. 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 a $190 
copayment for transthoracic echocardiography (C8929) and radiology/nuclear medicine service (78452).  
 
You have been asked to pay a $190 copayment for transthoracic echocardiography (C8929) and 
radiology/nuclear medicine service (78452). Transthoracic echocardiography (C8929) and radiology/nuclear medicine service (78452) falls within Other outpatient diagnostic tests - Radiological diagnostic services, 
not including x-rays 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 transthoracic 
echocardiography (C8929) and radiology/nuclear medicine service (78452) on November 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the therapy services. You say that you are in pain and would like for the 
services to be approved. The Plan denied your request. The Plan says there is an approved authorization with 
an in-network provider who provides the same quality of service and has available appointments. 
 
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 
the therapy services to be provided 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 telehealth specialist office visit provided on 
January 21, 2022. 
 
You asked the Plan to waive the copayment for telehealth specialist office visit. You say that you never saw the 
doctor on this date so it 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 $40 
copayment for each specialist office visit. 
 
You have been asked to pay $40 copayment for telehealth specialist office visit. Telehealth specialist office 
visits fall 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 telehealth specialist office visit provided on January 21, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on December 24, 
2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the hospital was not able to do the 
test you needed so they transferred you somewhere else. You should not be charged for them not being able to 
help you. 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 each Medicare-covered emergency room visit.  
 
You have been asked to pay $90 copayment for ER visit. ER visits 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 the ER visit provided on December 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hip arthroplasty (27130). 
 
You asked the Plan to pre-approve a total hip arthroplasty. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage of 
the requested services have not been met. 
 
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 total hip arthroplasty. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that detailed documentation is not evident in the available medical record regarding 
any left hip objective deficits on recent exam. Additionally, detailed documentation is not evident regarding 
trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. There are 
limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
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 total hip arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip arthroplasty (27130).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is in a lot of pain. The Plan 
denied your request. The Plan says there is no documentation of medial branch blocks. The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has low back pain and sacroiliac joint dysfunction. The request is for 
radiofrequency ablation of L5 and SI joint lateral branches as well as S2-S4 lateral branches. This procedure is 
considered experimental/investigational due to the wide variation in efficacy as documented in the peer 
reviewed literature. Therefore, 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on February 11, 
2022. 
 
You asked the Plan to waive the copayment for an eye exam. You say that usually they do both visits in one 
appointment, so you do not want to be charged for the other appointment. 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 $20 
copayment for each Medicare covered eye exam.  
 
You have been asked to pay $20 copayment for an eye exam. Eye exams fall within the Vision 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 eye exam provided on February 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty services. You asked the Plan to pre-approve the requested services. You say that the enrollee's back pain is not 
responding to conservative treatment. The Plan denied your request. The Plan says a bone density test has not 
been provided. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation is only covered 
under certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for wedge compression fracture of unspecified thoracic spine. 
She has had kyphoplasty before with good result including relief of similar pain at a different level. She has 
low back pain in a T10 distribution that is not responding to conservative treatment with an MRI showing acute 
to subacute fracture of the T10 vertebral body. However, detailed documentation is not evident regarding trial 
and failure of recent, reasonable, and comprehensive less invasive conservative care measures. She is not noted 
to be hospitalized or have severe pain greater than or equal to 8. There is no indication of progression of 
vertebral height loss. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception to guidelines. Therefore, the enrollees condition is not 
indicated for the requested services and the services are not medically 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve kyphoplasty services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that the CGM is medically 
necessary. The Plan denied your request. The Plan says you do not meet prior authorization criteria. 
 
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 perform blood 
glucose testing at least four times per day and use insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre 2 CGM sensor have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM) sensor.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for psychotherapy and office visits provided on 
February 4, 2022 and March 4, 2022. 
 
You asked the Plan to waive the copayment for psychotherapy and office visits. You say that you are appealing 
the denial of the services. 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 $40 
copayment for covered services which include: mental health services provided by a state-licensed psychiatrist 
or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician 
assistant, or other Medicare-qualified mental health care professional as allowed under applicable state laws.  
 
You have been asked to pay a total of $80 ($40 x 2 visits = $80). The psychotherapy and office visits 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 the copayment 
for psychotherapy and office visits provided on February 4, 2022 and March 4, 2022.