Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve 5 months of rental for Group 2 power wheelchair (K0823). 
 
You asked the Plan to pre-approve the 5 months of rental. You say that the power wheelchair was delivered 
October 6, 2021, and you have received 8 of 13 monthly payments. You need a continuation of care for 5 
months rent to cap with current dates of service. The Plan denied your request. The Plan says that the requested 
additional months exceed the benefit of 13 months. 
 
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. Rented DME is generally only covered by the Plan for 13 months, until which 
time ownership of the item will pass to the enrollee. The Plan has not provided any documentation that 13 
months of this item has been paid. In fact, the documents show that the Plan confirmed with the DME supplier 
that only 8 months have been paid for this item. Therefore, we decided that the Plan has to pre-approve 5 
months of rental for Group 2 power wheelchair (K0823).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has chronic obstructive pulmonary disease (COPD) with two recent hospitalizations. 
The enrollee improved on bilevel positive airway pressure (BiPAP) as an inpatient. This enrollee may benefit 
from BiPAP with average volume-assured pressure support (AVAPS) during sleep as an outpatient. This has 
not been tried and failed as an outpatient. Medicare does not cover a home ventilator when used as BiPAP.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee injections provided on August 01, 2022, to August 17, 
2022. 
 
You asked the Plan to pay for knee injections. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for knee injections provided 
on August 01, 2022, to August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on May 31, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
May 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-ray provided on October 06, 2022. 
 
You asked the Plan to waive the copayment for X-ray. You say that you are not paying this because you have 
had x-rays in the past with no cost sharing. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $20 
copayment for Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for X-ray. This item/service 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 X-ray provided on October 06, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by an 
in-network provider from April 28, 2022, to May 2, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are living on a 
fixed income. The Plan denied your request. The Plan says this cost sharing was charged 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 $300 
copayment per day, days 1-5, and a $0 copayment per day, days 6-90, for each in-network Medicare-covered 
hospital stay. 
 
 
 
 
 You have been asked to pay a $1200 copayment for the inpatient hospital stay ($300 x 4 days = $1200). This 
item/service 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 the inpatient hospital stay provided by an in-network provider from April 28, 2022, to May 2, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs, x-ray 
services, lab services, outpatient hospital services and physical therapy services September 12, 2022, to 
September 13, 2022. 
 You asked the Plan to waive the cost share for Medicare Part B prescription drugs, x-ray services, lab services, 
outpatient hospital services and physical therapy services. You say that you disagree with the cost share The 
Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for Medicare Part B prescription drugs, a $35 copayment outpatient diagnostic test/x-ray services, 
a $10 copayment for outpatient diagnostic test/lab services, a $290 copayment for outpatient hospital services 
and a $30 copayment per visit for outpatient rehabilitation services/Medicare-covered physical therapy 
services.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs, a $35 copayment 
outpatient diagnostic test/x-ray services, a $10 copayment for outpatient diagnostic test/lab services, a $290 
copayment for outpatient hospital services and a $30 copayment per visit for outpatient rehabilitation 
services/Medicare-covered physical therapy services. The total allowed amount for the prescription drugs is 
$349.90. You are being asked to pay $69.98 ($349.90 x 20% = $69.98). The total amount for the rehab services 
is $120 ($30 x 4 days = $120). The total amount you are being asked to pay for all services $524.98 ($290 + 
$35 + $10+ $120+ $69.98 = $524.98). 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 cost share for Medicare Part B 
prescription drugs, x-ray services, lab services, outpatient hospital services and physical therapy services 
September 12, 2022, to September 13, 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. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that no clinical information was received from the provider. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there is no documentation either medical or therapy notes to support necessity 
for admission to an IRF. While you may benefit from multiple therapies, your rehabilitation needs can be  provided in a lower intensity and alternate setting such as in a skilled nursing facility or initiate therapies at 
home with documentation of progress. 
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an external insulin infusion pump (E0784). 
 
You asked the Plan to pre-approve the external insulin infusion pump. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says that the services denied 
correctly as they do not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the external insulin infusion pump. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that the low c-peptide 
is diagnostic for t1 dm or insulinogenic.  If the pt. were insulinogenic in 2012, the enrollee would be in the 
same situation now unless the enrollee has had a pancreas transplant (which is not the case). Hence criteria are 
met. 
 
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 external insulin infusion pump have been met. Therefore, we decided that 
the Plan has to pre-approve an external insulin infusion pump (E0784).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for epidural steroid injection with imaging 
guidance provided on August 16, 2022. 
 
You asked the Plan to waive the copayment for epidural steroid injection with imaging guidance. You say that 
you should not have to pay this bill because you were not told in advance there was a copayment. The Plan 
denied your request. The Plan says this cost sharing was charged 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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $350 copayment for epidural steroid injection with imaging guidance. This 
item/service 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 epidural 
steroid injection with imaging guidance provided on August 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee surgery provided on March 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a knee surgery. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says there was no preauthorization by a primary care provider 
(this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 knee surgery provided on March 31, 2022, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an abdominal ultrasound provided on 
September 26, 2022. 
 
You asked the Plan to reduce the copayment for an abdominal ultrasound. You say that you think the cost 
sharing should be lower. The Plan denied your request. The Plan says this cost sharing was charged 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 $75 
copayment for Medicare-covered diagnostic radiology services, including ultrasounds, performed at a free-
standing facility. 
 
You have been asked to pay a $75 copayment for an abdominal ultrasound. This item/service falls within the 
Medicare-covered diagnostic radiology services, including ultrasounds, performed at a free-standing facility 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to reduce the copayment for an abdominal ultrasound 
provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry services provided on 
November 08, 2022. 
 
You asked the Plan to waive the copayment for the podiatry services. You say that the information you 
received was confusing. The Plan denied your request. The Plan says this cost sharing was charged 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 $45 
copayment for podiatry services. 
 
You have been asked to pay a $45 copayment for the podiatry services. This item/service falls within the 
podiatry 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 the podiatry services 
provided on November 08, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for psychotherapy visits provided on July 20, 
2022, to October 12, 2022. 
 
You asked the Plan to waive the copayment for psychotherapy visits. You say that you were told there was a $0 
copayment, so you should not have to pay for these services. The Plan denied your request. The Plan says this 
cost sharing was charged 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 $25 
copayment for Outpatient mental health care. 
 
You have been asked to pay a $25 copayment for psychotherapy visits. This item/service falls within the 
Outpatient mental health 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 
psychotherapy visits provided on July 20, 2022, to October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional acupuncture treatments. 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested services. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
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 requested services are not medically necessary. Our physician reviewer found that you have a diagnosis of 
pain in the right shoulder. You rated your overall progress since starting acupuncture as Excellent. You 
reported a pain level of eight over the previous week and on the day your response was submitted. The provider 
requested ten acupuncture visits and six were approved by the Plan. You reportedly utilized two of the 
approved acupuncture treatments for the period of December 21, 2022, through January 21, 2023. It is noted 
that the practitioner had not provided all of the requested records for review. It was recommended by the plan 
that you discuss your treatment options with your practitioner. The available documentation in the case file 
indicates that the first office visit under the Clinical Performance System was on November 18, 2022, and the 
last office visit was December 14, 2022. You were recommended to go to the clinic two times per week for five 
weeks. The documentation supports that the six approved acupuncture services were medically reasonable and 
necessary for you in this case. Necessity was supported by the nature and severity of your complaints, and it 
was reasonably expected that your symptoms would improve within a reasonable period of time. The 
documentation is insufficient to support that four additional visits for acupuncture treatment are medically 
reasonable and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 4 additional acupuncture treatments.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on June 17, 
2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $220 
copayment for outpatient surgery/vitality.  
 
You have been asked to pay a $220 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/vitality 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 
outpatient surgery provided on June 17, 2022.