Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from September 
16, 2021, to September 20, 2021. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you are receiving a bill from the 
hospital, and that your insurance should be responsible for it. 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 $325 
copayment for each Medicare-covered hospital stay for days 1-5 and a $0 copayment per day for days 6-90. For 
each Medicare-covered hospital stay, you are required to pay the applicable cost sharing, starting with Day 1 
each time you are admitted. Cost sharing does not apply on the day of discharge. 
 
 You have been asked to pay a total of $1,300 ($325 x 4 days = $1,300) for an inpatient stay. An inpatient stay 
falls with 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 hospital stay from September 16, 2021, to September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you need additional transportation 
approved because you have no other way to your appointments. The Plan denied your request. The Plan says 
you have used 10 trips and have exhausted the benefit. The Plan also says that additional trips are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 10 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urodynamic testing, or diagnostic testing for incontinence 
symptoms, provided on April 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for urodynamic testing. You say that the enrollee presented with Original Medicare. 
You say you were not aware that the enrollee has a Medicare Advantage Plan. The Plan denied your request. 
The Plan says a prior authorization was not obtained. The Plan also says that the enrollee does not meet any of 
the exceptions listed in the Plan contract that would allow coverage of the requested 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 urodynamic testing, or diagnostic testing for 
incontinence symptoms, provided on April 18, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99214) and electrocardiogram (93000) to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the physician services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says there are in-network providers available within a reasonable 
distance that can provide these services. The Plan also says that the requested services are not urgent or 
emergent in nature. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit (99214) and electrocardiogram (93000) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 additional non-emergent medical transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that you are partially blind and do not have access 
to transportation. You say that you live alone. You say that you were not aware that for one appointment you 
would be using two rides. You also say that you believe you were charged non-primary care provider (PCP) 
rides when you went to see your PCP. The Plan denied your request. The Plan says there is not an exception 
that would allow the plan to cover more than the 48 one-way rides to other healthcare-related locations covered 
by your plan. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of unlimited rides to your primary care physician (PCP), and up to 48 one-
way rides to other healthcare-related locations trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 15 additional non-emergent medical transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide twenty (20) additional routine transportation trips for 2022. 
 
You asked the Plan to provide additional transportation. You say that you have upcoming appointments and 
need this transportation. The Plan denied your request. The Plan says your benefit covers a maximum of 48 
routine transportation trips each year. Additional trips are not a covered benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide twenty (20) additional routine transportation trips for 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on April 21, 2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you have never had to pay 
anything for a colonoscopy before. 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 $50 
copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital 
facility. There are no cost sharing charges for a Medicare-covered screening colonoscopy; however, when a 
screening colonoscopy becomes a diagnostic procedure (biopsy or removal of a lesion or growth), then 
outpatient surgery cost sharing may apply. 
 
You have been asked to pay a $50 copayment for a colonoscopy. A colonoscopy 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 a colonoscopy provided on April 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Ultrasound and Electroencephalogram 
(EEG) provided on January 4, 2022, to January 5, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound and EEG. You say that you have had this testing 
before and have not had to pay this much. 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 $160 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic) and a $30 
copayment for Medicare-covered non-radiological diagnostic services. 
 
 You have been asked to pay a total of $190 ($160 and $30 = $190) for an ultrasound and EEG. An ultrasound 
and EEG 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 an Ultrasound and Electroencephalogram (EEG) provided 
on January 4, 2022, to January 5, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac rehabilitation services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve services at an out-of-network facility. You say that you would prefer to go 
to this facility as it is closer to your home. The Plan denied your request. The Plan says they agree these 
services are medically necessary, but there are in-network providers within a reasonable distance from you who 
can provide these services. The Plan has approved treatment with an in-network facility. 
 
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 
cardiac rehabilitation services to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
additional mileage to get to your medical appointment. The Plan denied your request. The Plan says your 
benefit only allows up to 24 one-way trips per year with each one-way trip not to exceed 50 miles. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation up to 24 one-way trips per year with each one-way trip not to 
exceed 50 miles.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 55.1 miles from your residence. Therefore, we decided that the Plan does not have to pre-approve 
additional mileage for routine transportation (A0170).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy with ultrasonic guidance. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of ultrasound for daily simply 
simulations and/or image guided radiation therapy (IGRT) has not been established by published data or 
supported by consensus guidelines. The request is not the standard of care and is not reasonable or medically 
necessary for the enrollee. 
 
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 radiation therapy with ultrasonic guidance.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The medical records show that the enrollee experience 60% pain 
relief for 3 weeks from the injection provided on July 22, 2022. The documentation does not show that three 
months of sustained pain improvement has been experienced. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve an epidural steroid injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting LTACH services for 
the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is 
currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is necessary as you have pain while 
walking. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee joint replacement joint surgery for the enrollee 
provided at in-network benefit level to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve knee joint replacement joint surgery provided at in-network benefit level. 
You say that these services are medically necessary. The Plan denied your request. The Plan says that there is a 
participating provider available for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that if you use an out-of-network provider, the enrollee's share of the costs for your covered services 
may be higher. 
 
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 services at an in-network level of care. Therefore, we decided that the Plan does 
not have to pre-approve knee joint replacement joint surgery for the enrollee provided at in-network benefit 
level to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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. 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 medically necessary. Our physician reviewer found the enrollee had a right below-
knee amputation and recent left lower limb infections. There are documented wound complications but no 
documentation to show that she required an intensive therapy program in an IRF, as she is ambulating short distances without assistance. The IRF services are therefore not reasonable or 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan of the brain and the whole body and CT 
scan of the thorax, abdomen and pelvis with contrast to be provided by the requested out-of-network provider. 
 
You asked the Plan to pre-approve a PET scan and a CT scan thorax, abdomen and pelvis with contrast to be 
provided by the requested out-of-network provider. You say that you have been going to this provider since 
2019. The Plan denied your request. The Plan says in most cases, care you receive from an out-of-network 
provider will not be covered except for emergency care or urgently needed services that you get from an out-
of-network provider, or if you need medical care that Medicare or Medicaid requires our Plan to cover and the 
providers in our network cannot provide this care, you can get this care from an out-of-network provider, which 
requires prior-authorization from the Plan before getting care and covers kidney dialysis services that you get at 
a Medicare-certified dialysis facility when you are temporarily outside the Plans service area. 
 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a PET 
scan of the brain and the whole body and CT scan of the thorax, abdomen and pelvis with contrast to be 
provided by the requested out-of-network provider.