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

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 11, 2021. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that this is a benefit that should be 
covered. 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 each specialist visit.  
 
You have been asked to pay a $40 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 waive the copayment for a specialist office visit provided on December 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for infusion services provided 
on December 29, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for the infusion. You say that you were not able to 
have the treatment through home health services for that week. The Plan denied your request. The Plan says the 
correct copayment and coinsurance were 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 
copayment for physician services in an outpatient facility. 
 
Your contract with the Plan also clearly says that you must pay a 10% coinsurance for each Part B drug. 
 You have been asked to pay a $20 copayment for the infusion services. The infusion falls within the Outpatient 
Hospital Services benefit category. You have also been asked to pay $482.20 for the Gamunex drug, which is 
10% of the allowed amount ($4,822.00 allowed amount x 10% coinsurance = $482.20). You have also been 
asked to pay $0.10 for the diphenhydramine drug, which is 10% of the allowed amount ($0.97 allowed amount 
x 10% coinsurance = $0.10). The drugs fall within the Medicare Part B Prescription Drugs Benefit category. 
The total for the services is $502.30. 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 and coinsurance for 
infusion services provided on December 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a magnetic resonance imaging (MRI) scan 
provided on April 6, 2022. 
 
You asked the Plan to waive the coinsurance for an MRI. You say that this should not be considered an out-of-
network service. 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 50% 
coinsurance for out-of-network advanced imaging services.  
 
You have been asked to pay a $182.34 coinsurance for an MRI ($364.68 x 50% = $182.34). An MRI falls 
within the out-of-network advanced imaging 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 
coinsurance for a magnetic resonance imaging (MRI) scan provided on April 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the intracept procedure is medically 
necessary and supported by strong science. You state that you would like to perform this procedure at L4 and 
L5 vertebral bodies on the enrollee. The Plan denied your request. The Plan says the enrollee's request is not 
medically necessary because there is little evidence in the medical literature to suggest that this is an 
appropriate procedure for their back pain. The Plan states the requested procedure is not an accepted standard 
of medical practice for the diagnosis or treatment of back pain and it is 
considered experimental and investigational. 
 
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 the intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT code 64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional reimbursement for a continuous positive airway 
pressure (CPAP) device provided on March 23, 2022. 
 
You asked the Plan to provide additional reimbursement for the CPAP device. You say that you were informed 
that you would be reimbursed for the cost of the machine. The Plan denied your request. The Plan says you 
have been reimbursed the correct 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 20% 
coinsurance for durable medical equipment (DME), including oxygen equipment.  
 
Per the EOC, the Plans responsibility for the claim is $49.87, which is 80% of the allowed amount of $62.34. 
Please note that the Plan cannot reimburse for costs in excess of the Medicare allowed amount. Therefore, you have been reimbursed the correct amount for the CPAP device. The CPAP device falls within the Durable 
Medical Equipment (DME) and Related Supplies benefit category. This means that you have been reimbursed 
the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to 
provide additional reimbursement for a continuous positive airway pressure (CPAP) device provided on March 
23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided in conjunction 
with an annual wellness visit on June 9, 2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that the lab work should be included 
in your annual wellness visit. 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 $10 
copayment per day for laboratory tests that are not FIT tests.  
 
You have been asked to pay a $10 copayment for the lab services. Please note that lab services go beyond the 
scope of an annual wellness visit and are subject to copayment. The lab services fall 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 laboratory services provided in conjunction with an annual wellness visit on June 9, 2022.
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 would like to receive more rehabilitation 
services. The Plan denied your request. The Plan says authorization denied because the IRF care is not 
medically necessary, and your needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 does not need a physician's supervision three times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. There are no acute rehabilitation nursing needs identified or documented. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy on April 07, 2022. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for surgical service at outpatient hospital facility. If you are having surgery in a hospital facility, 
you should check with your provider about whether you will be an inpatient or outpatient. Unless the provider 
writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing 
amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an 
outpatient. 
 
 
 
 
 You have been asked to pay a $325 copayment for colonoscopy. 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 colonoscopy on April 07, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF services. 
 
You asked the Plan to pre-approve continued SNF services. You say that continued services at the skilled 
nursing facility are medically necessary. The Plan denied your request. The Plan says rules for SNF care have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins the day you go into a hospital or skilled nursing 
facility. The benefit period ends when you havent received any inpatient hospital care (or skilled care in SNF) 
for 60 days in a row. 
 
The file shows that you received 100 days of SNF care during the benefit period from May 15, 2022, to 
September 4, 2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a specialist visit provided on March 7, 
2022. 
 
You asked the Plan to waive the coinsurance for a specialist visit. You say that the Plan should have covered 
this entire cost. 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 $1000 
deductible for Medicare covered physician specialist services.  
 
You have been asked to pay $562.96 of your $1000 deductible for a specialist visit. A specialist visit falls 
within the Medicare Covered Physician Specialist 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 coinsurance for a specialist visit provided on March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for knee brace on April 19, 2022. 
 
You asked the Plan to waive the coinsurance for knee brace. You say that you should not have to pay for the 
copayment for this as this is a rip-off especially since the doctor cannot take it back. The Plan denied your 
request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for covered items and related supplies for durable medical equipment (DME). Covered items 
include, but are not limited to wheelchairs, crutches, powered mattress systems, diabetic supplies, hospital beds 
ordered by a provider for use in the home, IV infusion pumps, speech generating devices, PAP therapy and 
oxygen equipment, nebulizers, and walkers. The provider billed in the amount of $205 and the allowed amount 
is $150.17. $150.17 x 20% = $30.03. Therefore, results in the total cost sharing amount of $30.03. 
 
 
 You have been asked to pay a 20% coinsurance for knee brace. Knee brace falls within the Durable medical 
equipment (DME) 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 knee brace on April 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker (E0143, E0156). 
 
You asked the Plan to pre-approve the walker. You say that the new walker is medically necessary. The Plan 
denied your request. The Plan says the record shows a walker was already delivered for the enrollee. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a walker. The walker already delivered serves the same purpose as the requested 
walker. Therefore, we decided that the Plan does not have to pre-approve a walker (E0143, E0156).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye appointment provided on January 
19, 2022. 
 
You asked the Plan to waive the copayment for an eye appointment. You say that you should not have to pay 
this copayment because you feel the provider did not do anything. 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 vision care - Medicare covered vision services.  
 
You have been asked to pay a $50 copayment for an eye appointment. An eye appointment falls within the 
Vision Care - Medicare Covered Vision 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 eye appointment provided on January 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a physical therapy visit provided on April 
14, 2022. 
 
You asked the Plan to waive the copayment for a physical therapy visit. You say that you should not have to 
pay this copayment. 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 $30 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $30 copayment for a physical therapy visit. A physical therapy visit falls within 
the Outpatient Rehabilitation Services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
physical therapy visit provided on April 14, 2022.
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 authorization denied because the IRF care is not 
medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility (SNF). The Plan denied your request. The Plan says the IRF care is 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 the enrollee is medically stable and does not need a physician's supervision three 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. There are no acute rehabilitation nursing needs identified or documented. 
 
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: 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 enrollee has been a patient at this 
facility for 31 days now. The Plan denied your request. The Plan says based on Medicare guidelines, the 
LTACH services being requested do not meet the requirements for approval. 
 
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 medical records do not indicate that the enrollee requires services that she is not 
currently receiving, but that would be available at the LTACH facility. 
 
 
 
 
 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a sensorimotor eye test provided on April 
19, 2022. 
 
You asked the Plan to waive the copayment for the sensorimotor eye test. You say that the doctor ordered the 
test and you should not have to pay for it. 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 $55 
copayment for each diagnostic procedure or test at a network doctor's office.  
 
You have been asked to pay a $55 copayment for the sensorimotor eye test. The sensorimotor eye test 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 sensorimotor eye test provided on April 19, 2022.