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

 
We decided that the Plan does not have to waive the copayments for urgent care visit on August 11, 2021, to 
August 24, 2021. 
 
You asked the Plan to waive the copayments for urgent care visit. You say that you were under the impression 
that everything would be covered regardless of the venue in which they received the Covid-19 test. 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 $45 
copayment for each covered office visit to other providers for urgently needed services. Urgently needed 
services are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires 
immediate medical care. Urgently needed services may be furnished by network providers or by out-of-
network providers when network providers are temporarily unavailable or inaccessible. Provider billed in the 
amount of $90 and the allowed amount is $24.14. There were 2 visits, resulting in the amount of $48.28, which 
is less than the copayment amount. Therefore, result in the total cost sharing amount of $48.28. You have been asked to pay a $24.14 copayment for each urgent care visit, which is less than the copayment 
amount. Urgent care visits fall 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 copayments for urgent care visit on August 11, 2021, to August 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
September 3, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you feel you out-of-
pocket maximum had been reached. 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 $230 
copayment for each one-way ambulance trip. 
 The file shows that at the time the ambulance claim was received and processed by the Plan, your out-of-pocket 
maximum had not been met. Therefore, you have been asked to pay a $230 copayment for the ambulance 
transportation. The ambulance transportation falls within the Ambulance 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 ambulance transportation provided on September 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a walker provided on September 27, 2021. 
 
You asked the Plan to waive the coinsurance for a walker. You say that you should not have to pay for this 
coinsurance. 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 20% 
coinsurance for durable medical equipment (DME). The allowed amount of this item is $50.87 resulting in a 
coinsurance amount of $10.17 ($50.87 x 20% = $10.17).  
 
You have been asked to pay a 20% coinsurance for a walker. a walker falls within the Durable Medical 
Equipment (DME) 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 walker provided 
on September 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of arteries in the head and 
neck provided on March 9, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you only had one ultrasound 
performed. 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 $60 
copayment for each X-ray and ultrasound.  
 
You have been asked to pay $20, which is less than the $60 copayment for the ultrasound. Please note that 
while one procedure was performed, there were multiple studies done. The ultrasound 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 of arteries in the head and neck provided on March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted multianalyte assay with algorithmic analysis (81599) 
provided April 5, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting this claim to be 
reprocessed and paid. The DecisionDx-SCC test is a covered Medicare benefit. The Plan denied your request. 
The Plan says under Medicare rules, this test is not a covered benefit. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. Review of authoritative medical literature does notsupport that 
this testing has demonstrated analytic and clinical validity and utility in determining the risk of developing 
metastatic disease, and this test has not met the MolDX review to determine if this test meets the Medicares 
reasonable and necessary requirement. Based on this information, we decided that Medicare rules for coverage 
of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for 
unlisted multianalyte assay with algorithmic analysis (81599) provided April 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service from 
December 1, 2021, to December 30, 2021. 
 
You asked the Plan to pay for home health services. You say that you have provided medical records to support 
the services at issue. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The plan must follow Medicare rules. The rules say that the RAP must be submitted within five calendar days 
after the start of care for home health services. 
 
 
 We looked at the file and Medicare rules. In this case, the services at issue are not supported because there is no 
evidence in the case record that a valid RAP was submitted for the services. 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 pay for home health services billed for dates of service from December 1, 2021, 
to December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99231) provided on February 2, 
2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that the services at issue were provided after 
the enrollee was admitted into the hospital. The Plan denied your request. The Plan says rules for payment have 
not been met because the services at issue were billed with an incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
 
  We find that CPT code 99231 is not supported. Specifically, the services at issue were billed as inpatient. The 
record shows that all other services from the date of service at issue were billed as outpatient. Based on this 
information, we decided that Medicare rules for coverage of subsequent hospital care have not been met. 
Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99231) provided on 
February 2, 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 April 12, 2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that there should be no charge for 
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 no 
coinsurance, copayment, or deductible for the annual wellness visit. If you receive services that address a 
medical condition during the same office visit, additional cost share may apply. 
 Your contract with the Plan also clearly says that you must pay a $10 copayment per day for laboratory tests 
that are not FIT tests. 
 
The file shows that you had the lab services performed along with your annual wellness visit. These services go 
beyond the scope of the wellness visit and are subject to copayment. Therefore, you have been asked to pay a 
$10 copayment for the lab services. The lab services 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 
laboratory services provided in conjunction with an annual wellness visit on April 12, 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 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 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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601). 
 
You asked the Plan to pre-approve a CPAP device. You say that you have sleep apnea, and you cannot sleep. 
Your doctor thought the device was necessary for your sleep apnea. The Plan denied your request. The Plan 
says they contacted your primary care physician's office multiple times and did not receive needed information 
that includes settings describing what range of pressure should be used to activate the device. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CPAP device have not been met. Specifically, Medicare rules say that in order to provide you 
with a CPAP device, the physician order must include pressure settings. The records show that the Plan 
contacted your primary providers office multiple times, and the information was not received. Therefore, we 
decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have iron deficiency anemia and has not tried oral iron. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Injectafer. Our reviewer says that the 
submitted records do not show that Injectafer is medically necessary. Our physician reviewer found the records 
do not document iron deficiency to support the use of the Injectafer. The latest records provided show normal 
iron, ferritin, iron binding capacity, and iron saturation levels. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crutch substitute for the lower leg and a fluid circulating 
cold pad with pump provided from January 15, 2022, to January 26, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for a crutch substitute for the lower leg and a fluid circulating cold pad with pump. 
You say that you were completely unaware that pre-approval was needed prior to your rental/purchase of the 
medical equipment. You also say that it is your understanding that the surgeon was responsible for that. The 
Plan denied your request. The Plan says the items were obtained from a provider who is not under contract with 
the Plan, is not certified for Medicare, and was not authorized with the Plan. 
 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 crutch substitute for the lower leg and a fluid 
circulating cold pad with pump provided from January 15, 2022, to January 26, 2022, by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on February 1, 2022. 
 
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says the hearing benefit 
is not covered if the services are not registered in advance. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plans 
hearing provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids 
have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on 
February 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy appointments provided 
from March 1, 2022, to March 31, 2022. 
 
You asked the Plan to waive the copayment for physical therapy appointments. You say that you should not 
need 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 $25 
copayment for physical and speech therapy services ($25 x 7 visits = $175). 
 
 
 
 
 
 
 You have been asked to pay a $175 copayment for physical therapy appointments. Physical therapy 
appointments fall within the Physical and Speech Therapy 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 physical therapy appointments provided from March 1, 2022, to March 31, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy provided on April 26, 2022. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that you should only have to pay one 
copayment for two different dates of service. 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 $45 
copayment for specialist visit for Medicare-covered services.  
 
 
 
 
 
 
 You have been asked to pay a $45 copayment for an endoscopy. an endoscopy falls within the Specialist Visit 
For Medicare-covered 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 endoscopy provided on April 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Tenex procedure (27299). 
 
You asked the Plan to pre-approve a Tenex procedure. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says medical-necessity rules for coverage have not 
been met because the requested services are experimental/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 a Tenex procedure. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is limited published, large-scale, long-term, peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for your pathology. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
 
  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 Tenex procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Tenex procedure (27299).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 24, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on February 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that the service was medically necessary. The Plan denied 
your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
drug testing. We found no exception that would require the Plan to pay for the drug testing. The records 
provided for review do not show that the drug testing was urgent or emergent. Therefore, we decided that the 
Plan does not have to pay for drug testing provided on February 17, 2022, by an out-of-network (OON) 
provider.