Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. Your medical status does not require intensive physician and nursing oversight in an IRF. While you may benefit from additional multiple therapies, including 
physical and occupational therapy, the documentation does not reveal that you require this therapy on an 
intensive IRF level. Our physician reviewer found that your 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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON physical therapy services. You say that there are no network 
providers who offer lymphatic services or wound care. The Plan denied your request. The Plan says the 
services needed are available within the 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 verified with the Plan that they have 
network providers who specifically offer lymphatic services and wound care. We found no exception that 
would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have 
to pre-approve physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services rendered by the out-of-network (OON) 
provider on January 24, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the medical services were rendered by an out 
of network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the medical services rendered by the out-of-network (OON) provider on  
January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit services provided on January 
13, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit services. You say that the assisted living facility 
is responsible to obtain prior authorization for all of their patients, which should also cover for the medical 
treatments provided by this provider. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan, and based on the documentation submitted, they have determined that the 
services rendered to the member are not urgent or emergent, nor were they approved in advance by a network 
provider. 
 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 a domiciliary or rest home visit services provided 
on January 13, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an x-ray provided on October 11, 2021. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you are being billed for services which 
were unexpected. You state that you were at an in-network facility with prior authorizations. The Plan denied 
your request. The Plan says that you have been charged the correct coinsurance amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay 35% coinsurance for out-of-network Medicare-covered x-
rays. The plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide information showing the allowed amount of this claim. 
Without knowing the allowed amount, we cannot determine whether the amount you are being asked to pay is 
appropriate for 35% coinsurance. Therefore, the Plan has not shown that its decision to ask you to pay $8.94 is 
correct or justified according to your contract with the Plan. Therefore, we decided that the Plan has to waive 
the copayment for an x-ray provided on October 11, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health hours per week. 
 You asked the Plan to pre-approve home health services. You say that you need additional personal care 
assistant (PCA) help to what your family is able to provide. The Plan denied your request. The Plan says you 
have adequate help for your needs. The Plan also says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found the 
enrollee is medically stable without any recent hospitalizations or medical complications. Therefore, the 
reviewer found that the requested daily hours of home health services are not needed to provide adequate 
support 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health hours per week.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on December 
17, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you only went for a COVID-
19 test. 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 $15 
copayment for each urgent care visit with a provider other than your PCP.  
 
You have been asked to pay a $15 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently Needed 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 copayment for an urgent 
care visit provided on December 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
LTACH care. You say that you are getting weaker and cannot stay in the hospital. The Plan denied your 
request. The Plan says the guidelines for coverage have not been met. The Plan says that the services needed 
could be provided in another setting. 
 
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 currently undergoing treatment at an acute care hospital (ACH) for 
osteomyelitis of the foot.  The enrollee is receiving wound care and a prolonged course of antibiotics.  The 
enrollee is not intubated/ventilated.  There is no evidence that the enrollee requires services that are not 
currently available.  As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until such 
time no acute services are required.  The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next test strips for the enrollee. 
 
You asked the Plan to pre-approve Contour Next test strips. You say that the enrollee needs the test strips. The 
Plan denied your request. The Plan says that there is no reason the enrollee can't use the preferred products. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must 
document in the beneficiarys medical record the reason why the specific brand or mode of delivery is 
necessary to avoid an adverse medical outcome. 
 
We looked at the file and Medicare rules. The file does not include any documentation why the enrollee 
requires this specific brand of test strips. Without this, medical necessity cannot be established. Therefore, we 
decided that the Plan does not have to pre-approve Contour Next test strips for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 4, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee was seen for medical necessity, and you 
would like a retro authorization. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved authorization. Also, the service 
rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 4, 2022, by an 
OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit on December 25, 
2021. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you had no treatment, so 
you should not have to pay this bill. The Plan denied your request. The Plan says coinsurance 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 emergency care visit.  
 
You have been asked to pay $90 copayment for the emergency room visit. The emergency room visit falls 
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 emergency 
room visit on December 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for substance abuse services provided from January 4, 2021, to August 2, 2021.
You asked the Plan to waive the copayments for substance abuse services. You say that it was your understanding that if you provided the receipts to the Plan, you would be refunded for the services. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for in-network substance abuse services provided in a specialist's office. The record shows these claims were approved, and you have a cost sharing amount. You have been asked to pay a $40 copayment for each substance abuse visit from January 4, 2021, to August 2, 2021.
Substance abuse services fall within the Outpatient Substance Abuse 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 substance abuse services provided from January 4, 2021, to August 2, 2021.
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 
thorax provided on January 10, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you are undergoing treatment and 
have not been charged for the imaging before. 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 $100 
copayment per day for diagnostic radiology services, such as CT scans.  
 
 
 You have been asked to pay a $100 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 thorax provided on January 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services (A0427, A0425) 
provided on April 15, 2021. 
 
You asked the Plan to pay for ambulance services. You say that these services were medically necessary and 
were billed appropriately. This transport was from the enrollees residence to the hospital, where they were later admitted. The Plan denied your request. The Plan says the enrollee was admitted to the hospital with an 
admission date of April 14, 2021, and a discharge date of May 10, 2021. Because the enrollee was inpatient on 
the date in question, the payment for this transport is included in the payment for the inpatient care. If the 
provider determines that a billing error occurred during the initial submission of the denied claim, the Plan 
would accept a submission of a corrected claim to consider services for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the ambulance services are not supported in the medical record for separate payment under Part B. 
Specifically, documentation shows that the enrollee was admitted as inpatient in the hospital from April 14, 
2021, to May 10, 2021. Therefore, we decided that the Plan does not have to pay for the ambulance 
transportation services (A0427, A0425) provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on 
February 14, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $5 
copay for Medicare-covered primary care physician (PCP) services (including telehealth services, nationally 
contracted walk-in-clinic services, and urgently needed services).  
 You have been asked to pay a $5 copayment for the Medicare-covered primary care physician service 
provided. 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 office visit (99214) provided on  
February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a glycosylated hemoglobin test and an office visit provided 
on March 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a glycosylated hemoglobin test and an office visit. You say that this was your 
semi-annual visit to this provider. You also say that you have had diabetes for several years, and they are in 
your network, and they have paid for your visits many times. The Plan denied your request. The Plan says that 
this provider is not an in-network provider. The Plan also said that you need to see in-network providers 
according to your contract or your primary care physician would need to request an out-of-network referral, 
and if approved, you would be able to see the out-of-network provider. The Plan also says that no out-of-
network referral has ever been requested for services at this provider. 
 
 
 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 a glycosylated hemoglobin test and an office visit 
provided on March 10, 2022, by an out-of-network (OON) provider.