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

 
We decided that the Plan does not have to waive the copayment for an MRI scan of the brain stem without 
contrast dye provided on January 24, 2022. 
 
You asked the Plan to waive the copayment for an MRI scan. You say that you should not be responsible for 
the copayment because you were supposed to have this MRI procedure six days earlier when you received a 
different scan. You say you were told to come back another day due to unforeseen problems with the order. 
You say the provider should be responsible for this copayment because their mistake caused you to have the 
procedure on a different day. The Plan denied your request. The Plan says the copayment was applied 
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 $150 
copayment for each Medicare-covered MRI.  
 
 You have been asked to pay a $150 copayment for an MRI. MRI scans fall within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. The contract also states the copayment applies to 
each individual scan, rather than per visit. 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 magnetic 
resonance imaging (MRI) scan of the brain stem without contrast dye provided on January 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a hyaluronan acid injection provided on 
September 2, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were charged for out-of-
network services. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 Part B drugs. You have been asked to pay $14.61, which is 20% of the allowed amount for the injection ($73.04 allowed 
amount x 20% coinsurance = $14.61). The injection falls 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 coinsurance for a hyaluronan acid injection provided on 
September 2, 2021.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member's medical needs can be met at lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a urinary tract 
infection in May of 2022 and was discharged home. There is ongoing weakness at home. The enrollees 
medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 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 patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the annual wellness visit and office visit provided on July 29, 2021. 
 
You asked the Plan to pay for the annual wellness visit and office visit. You say that the claim was submitted 
untimely because it was sent to the secondary payer first. You say that the Plans need to coordinate benefits to 
correct the denial of payment. The Plan denied your request. The Plan says that the claim processed correctly. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has not sent 
the bill directly to the primary insurer for payment, directed the provider to send the bill directly to the primary 
insurer or paid for the services and then submitted a bill for reimbursement to the primary insurer. Therefore, 
we decided that the Plan has to pay for the annual wellness visit and office visit provided on July 29, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard  hard appliance, full arch (D9944) 
provided February 28, 2022. 
 
You asked the Plan to pay for the mouth guard. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is not covered under your benefits. 
 
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 pay for the 
occlusal guard  hard appliance, full arch (D9944) provided February 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your needs can be 
met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are medically stable and no acute rehab nursing needs were identified or 
documented. While you may benefit from continued physical and occupational therapy, your rehab needs can 
safely be provided in a lower intensity setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
December 23, 2021, to December 27, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you cannot afford the 
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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $325 per 
day for days 1-5 and $0 per day for additional days for each inpatient admission.  
 
The file shows that you were in the hospital from December 23, 2021, to December 27, 2021, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $325 per day for the first 4 days of 
inpatient care. The total for your stay is $1,300 ($325 copayment x 4 days = $1,300). 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 December 23, 2021, to December 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio for the enrollee. 
 
You asked the Plan to pre-approve Entyvio. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred drug would likely be less effective, and/or 
cause adverse effects for the member. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Entyvio. Our reviewer says that 
Entyvio is not medically reasonable and necessary. There is no indication that the patient has tried and failed 
Stelara. Based on the medical records provided and the Medicare-approved major drug compendia there is no 
indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for the 
patient. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for 
Entyvio. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on January 14, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the copayment amount is too high. 
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 per day for diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay a $250 copayment for the CT scan. The CT scan 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 a computed tomography (CT) 
scan of the abdomen and pelvis provided on January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
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 an implantable loop recorder. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation provided to suggest a history of unexplained 
syncope, cryptogenic stroke or any other apparent indication for an ILR.  In summary, there is insufficient 
documentation to support the medical necessity for insertion of an ILR in this enrollees clinical management. 
 
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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, including programming 
(33285).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for diagnostic or therapeutic nerve blocks and injections 
(01992) provided on September 13, 2021. 
 
You asked the Plan to pay for anesthesia. You say that monitored anesthesia is medically necessary and a 
covered benefit for those patients that suffer from specified co-morbidities. The Plan denied your request. The 
Plan says that anesthesia services are considered incidental to the procedure performed. The Plan also says the 
reconsideration was not forwarded to the correct department for handling and the Plan was unable to make a 
decision within the 60-day time frame. 
 
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. Therefore, we decided that the Plan has to pay for anesthesia for diagnostic or 
therapeutic nerve blocks and injections (01992) provided on September 13, 2021.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance services (A0426, A0425). 
 
You asked the Plan to pre-approve non-emergency ambulance services. You say that this service is medically 
necessary and should be a covered benefit. The Plan denied your request. The Plan says the service at issue is 
not medically necessary due to a lack of information. 
 
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 non-emergency ambulance services 
(A0426, A0425) have been met. There are no medical records that explain why this service is needed. A new 
request can be made to the Plan when records supporting the need for this transportation are obtained. 
Therefore, we decided that the Plan does not have to pre-approve non-emergency ambulance services (A0426, 
A0425).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for administration of unclassified drugs for 
bladder treatment provided on January 28, 2022. 
 
You asked the Plan to waive the coinsurance for the drugs. You say that these drugs were covered in the past. 
The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 each Part B drug. 
 
Drug Allowed Amount 20% Coinsurance 
Unclassified (J3490) $105.35 $21.07 
 $105.35 $21.07 
Total:  $42.14 
 You have been asked to pay $42.14, which is 20% of the allowed amount for the drugs. The drugs 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 coinsurance 
for administration of unclassified drugs for bladder treatment provided on January 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
knee provided on February 21, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you cannot afford the 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment per day for diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay a $250 copayment for the MRI. The MRI 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 a magnetic resonance imaging (MRI) of the knee provided on February 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for urostomy supplies provided on March 3, 
2022. 
 
You asked the Plan to waive the coinsurance for the urostomy supplies. You say that you previously paid only 
$1 per year for the supplies. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 medical supplies. 
 
Item Allowed Amount 20% Coinsurance 
Drainage Bag (A4357) $11.96 $2.39 
Adhesive Remover Solvent (A4455) $8.75 $1.75 
Adhesive Wipes (A4456) $10.50 $2.10 
Total:  $6.24 You have been asked to pay $6.24, which is 20% of the allowed amount for the urostomy supplies. The 
urostomy supplies 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 urostomy supplies provided on March 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alcohol or peroxide supply per pint (A4244) provided on 
October 22, 2021. 
 
You asked the Plan to pay for alcohol or peroxide supply. You say that the service at issue was an emergency 
service and medically needed for the enrollee. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code A4244 has a status indicator of X on the Physician Fee Schedule. This means that CPT code A4244 is not payable. Based on this information, we decided that Medicare rules for coverage of alcohol 
or peroxide supply have not been met. Therefore, we decided that the Plan does not have to pay for alcohol or 
peroxide supply per pint (A4244) provided on October 22, 2021.