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

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve therapy services. You say that you want to try aquatic therapy. The Plan 
denied your request. The Plan says these services are available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 1 hour a day, Monday through Friday of 
home health aide services. 
 
You asked the Plan to pre-approve an additional 1 hour a day, Monday through Friday of home health aide 
services. You say that the additional 1 hour a day, Monday through Friday of home health aide services is 
medically necessary. The Plan denied your request. The Plan says the additional 1 hour a day, Monday through 
Friday of home health aide services is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 an additional 1 hour a day, Monday 
through Friday of home health aide services. Our reviewer says that the additional 1 hour a day, Monday 
through Friday of home health aide services is not medically necessary. Our physician reviewer found you are medically stable without any recent hospitalizations or medical complications.  The approved weekly hours of 
HHA services authorized by the health plan allow for appropriate support and care.  The documentation 
indicates you require custodial care and that the additional hours are not needed to provide adequate support for 
you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional 1 hour a day, Monday through Friday of home health aide services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 1 hour a 
day, Monday through Friday of home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cooled radiofrequency neuroablation of the genicular 
nerves. 
 
You asked the Plan to pre-approve cooled radiofrequency neuroablation of the genicular nerves. You say that 
the requested cooled radiofrequency neuroablation of the genicular nerves is medically necessary. The Plan 
denied your request. The Plan says the requested cooled radiofrequency neuroablation of the genicular nerves 
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 cooled radiofrequency neuroablation of 
the genicular nerves. Our reviewer says that the requested cooled radiofrequency neuroablation of the genicular 
nerves is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of pain in the 
right and left knees. There is insufficient support in the medical literature regarding the efficacy and safety of 
cooled radiofrequency neuroablation of the genicular nerves for the treatment of knee pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cooled radiofrequency neuroablation of the genicular nerves have not been met. 
Therefore, we decided that the Plan does not have to pre-approve cooled radiofrequency neuroablation of the 
genicular nerves.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Droxidopa. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Droxidopa.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says based on Medicare guidelines, the request for IRF services does not meet the 
requirements for approval. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for heart attack and congestive heart failure. The enrollees medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation provided on 
November 12, 2021. 
 
You asked the Plan to waive the copayments for the ambulance transportation. You say that you should not 
have to pay for the ambulance since the hospital did not have the right equipment. 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 $250 
copayment for each one-way ambulance transport.  
 
You have been asked to pay $222.32 for each transport, which is less than the $250 copayment. The total for 
both trips is $444.64. The ambulance transportation falls within the Ambulance Services benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for ambulance transportation provided on November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care services performed on 
February 1, 2022. 
 
You asked the Plan to waive the copayment for the wound care. You say that this service was already paid by 
insurance. 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 $150 
copayment per visit to an outpatient hospital facility.  
 
You have been asked to pay a total of $120.30, which is less than the $150 copayment for the wound care. The 
wound care 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 
wound care services performed on February 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for an out-of-network (OON) 
surgical procedure performed from February 24, 2022, to February 25, 2022. 
 
You asked the Plan to waive the deductible and coinsurance for the OON surgery. You say that you were not 
aware of the cost sharing at the time of service. The Plan denied your request. The Plan says the correct 
deductible and coinsurance were applied. 
 
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 $800 deductible which applies to certain items and services. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for out-of-network surgery 
services. 
 
The OON surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $800 deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not been met at the time the OON surgery was performed from 
February 24, 2022, to February 25, 2022.  
 
The file shows that the Plan verified the facility is not a network facility. The file also shows that on the dates 
of service, you had a total of 613.60 remaining to meet your deductible. This amount was applied first, leaving 
a remaining allowed amount of $28,727.34. Of this amount, you have been asked to pay a total of $9,149.87, 
which is less than the 50% coinsurance for the OON surgery. This amount is lower due to meeting your 
maximum out-of-pocket (MOOP) expenses for year. The total for the procedure is $9,826.77. Therefore, we 
decided that the Plan does not have to waive the deductible and coinsurance for an out-of-network (OON) 
surgical procedure performed from February 24, 2022, to February 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary. The Plan 
denied your request. The Plan says an IRF admission is not medically 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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for back pain. The enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
March 17, 2022, to March 21, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you received a staph infection 
during your stay and feel you should not have to pay. 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 $295 
copayment for each inpatient stay.  
 
You have been asked to pay a $295 copayment for the inpatient care. The inpatient care 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 care provided from March 17, 2022, to March 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on April 4, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you do not understand why this 
copayment is so large. The Plan denied your request. The Plan says the copayment amount applied was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $125 copayment for outpatient diagnostic tests and therapeutic services and supplies. Youve paid 
$40 towards the $125, so you currently owe $85, per the plan. 
 
The enrollee has been asked to pay a $125 copayment for a CT scan. A CT scan falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and supplies benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for a CT scan provided on April 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for medication injections provided on April 26, 
2022. 
 
You asked the Plan to waive the copayment for medication injections. You say that you feel you should not 
have to pay this coinsurance. The Plan denied your request. The Plan says the coinsurance applied was 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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this item is $1,828.40, resulting in 
a coinsurance amount of $365.68 ($1,828.40 x 20% = $365.68). 
 
You have been asked to pay a $365.68 coinsurance for medication injections. Medication injections fall within 
the Medicare Part B Prescription Drugs 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 medication injections provided on April 26, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that physical therapy is medical necessary. The Plan 
denied your request. The Plan says the coverage criteria has not been met. 
 
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 therapy 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 that the enroll has previously been treated with outpatient therapies 
and should be independent with a home exercise program.  There is no documentation of a recent injury or 
decline in function. The additional therapy services are not an appropriate duration and frequency for treatment 
of the enrollees medical condition and therefore 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 therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 15 physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from February 
14, 2022, to February 15, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you should not have to pay this 
copayment because you are dissatisfied with the room and bed you stayed in. The Plan denied your request. 
The Plan says the copayment applied was 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 $275 
copayment per day for days 1 through 6 for inpatient hospital care.  
 
You have been asked to pay a $275 copayment for an inpatient stay. An inpatient 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 an inpatient stay provided 
from February 14, 2022, to February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit provided on May 9, 
2022. 
 
You asked the Plan to reduce the copayment for the specialist visit. You say that your copayment should only 
be $35 for a specialist. 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 $48 
copayment for specialist services from a provider other than a Level 1 specialist.  
 
The file shows that the Plan verified the provider is not a Level 1 specialist. Therefore, you have been asked to 
pay a $48 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner Services, 
Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for a 
specialist office visit provided on May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for catheters provided from January 18, 2022, 
to April 20, 2022. 
 
You asked the Plan to waive the coinsurance for catheters. You say that you understand what the charge is, but 
you do not understand why this item is being classified as DME. The Plan denied your request. The Plan says 
the coinsurance applied was correct. The catheters are not classified as DME, but as prosthetic devices and 
related supplies, which has the same 20% coinsurance. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for prosthetic devices and related supplies. The allowed amount of this item is $772, resulting in a 
coinsurance amount of $154.40 ($772 x 20% = $154.40). 
 
You have been asked to pay a $154.40 coinsurance for catheters. Catheters fall within the Prosthetic Devices 
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 catheters provided from January 18, 2022, to 
April 20, 2022.