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

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
July 14, 2022, to July 20, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you are living on a 
fixed income, and this has been an overwhelming financial burden. 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 each time you are 
admitted to an acute care hospital, you pay $275 per day for days 1-5 and $0 after day 5. 
 
You have been asked to pay $1,375 for inpatient hospital care ($275 x 5 days). 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 care provided from July 14, 2022, to July 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided on March 
28, 2022, to March 31, 2022. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you shouldnt have to pay 
for this. 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 $30 
copayment for Outpatient rehabilitation services. 
 
You have been asked to pay a $30 copayment for physical therapy visits. This item/service 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. You have been asked to pay $60 ($30 x 2 visits) copayment for your physical 
therapy visits. Therefore, we decided that the Plan does not have to waive the copayment for physical therapy 
visits provided on March 28, 2022, to March 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $195 copayment for diagnostic testing. 
 
You asked the Plan to waive the $195 copayment for diagnostic testing. 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 $195 
copayment for all other diagnostic and nuclear medicine radiological services.  
 
You have been asked to pay $195 copayment for all other diagnostic and nuclear medicine radiological 
services for diagnostic testing. This item/service falls within the nuclear medicine radiological 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 $195 copayment for diagnostic testing.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fulphila. 
 
You asked the Plan to pre-approve Fulphila. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Fulphila. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drugs. There is no documentation provided indicating that the plans required drugs likely be 
less effective and/or likely have adverse effects 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 Fulphila have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Fulphila.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on August 15, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that your primary care physician was 
not available. 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 each covered visit or consultation in an outpatient location with a specialist. 
 
You have been asked to pay a $45 copayment for an office visit. This item/service falls within the each covered 
visit or consultation in an outpatient location with a specialist 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 office visit provided on August 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4557 and 99360 billed for date of service 
July 19, 2022. 
 
You asked the Plan to pay for procedure codes A4557 and 99360. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says procedure codes A4557 and 99360 are considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4557 has a status indicator of P on the Physician Fee Schedule. We find that 
procedure code 99360 has a status indicator of B on the Physician Fee Schedule. This means that procedure 
codes A4557 and 99360 are not separately payable. Based on this information, we decided that Medicare rules 
for coverage of procedure codes A4557 and 99360 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes A4557 and 99360 billed for date of service July 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs provided on September 22, 
2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you shouldnt have to pay for this. 
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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Part B drugs. This item/service falls within the Medicare Part 
B prescription drugs 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. You have been asked to pay $28.98 which is 20% of the allowed amount for Part B drugs. 
Therefore, we decided that the Plan does not have to waive the coinsurance for Part B drugs provided on 
September 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
on May 30, 2022, to May 31, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. You say that this should be 
covered. 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 $178 
copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $178 copayment for skilled nursing facility (SNF) care. This item/service falls 
within the Skilled nursing facility (SNF) 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. You have been asked to pay $356 ($178 x 2 days) copayment for SNF care. 
Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) 
care provided on May 30, 2022, to May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and panoramic 
radiographic imaging (D0330) provided on November 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed these services provided. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 5, 2022. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and panoramic 
radiographic imaging (D0330) provided on November 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs provided on July 28, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that this should be covered. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Part B drugs. This item/service falls within the Medicare Part 
B prescription drugs 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. You have been asked to pay $267.12 which is 20% of the allowed amount for the Part B drugs. 
Therefore, we decided that the Plan does not have to waive the coinsurance for Part B drugs provided on July 
28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from July 4, 2022, to August 2, 2022. 
 
You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says SNF care was no longer 
required. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from July 4, 2022, to August 2, 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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the request is not medically necessary, the services the enrollee needs can 
be provided safely in other settings, for example, a skilled nursing facility. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different level of 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on August 10, 
2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the assisted living facility is 
responsible for obtaining authorization. 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 the domiciliary or rest 
home visit provided on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a procedure provided on August 15, 2022. 
 
You asked the Plan to pay for a procedure. 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 a procedure provided on 
August 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 95907, 95886, and 95937 billed for date of service 
July 8, 2022. 
 
You asked the Plan to pay for codes 95907, 95886, and 95937. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT codes 95907, 95886, and 95937 are not supported in the medical record. Specifically, the 
technical report did not include documentation of nerve conduction studies; 1-2 studies; therefore, code 95907 
cannot be verified. 
The technical report did not include documentation of a Needle electromyography, each extremity, with related 
paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels 
(Listed separately in addition to code for primary procedure); therefore, code 95886 cannot be verified. 
 
The technical report did not include documentation of neuromuscular junction testing (repetitive stimulation, 
paired stimuli), each nerve, any 1 method; therefore, code 95937 cannot be verified. 
Based on this information, we decided that Medicare rules for coverage of codes 95907, 95886, and 95937 
have not been met. Therefore, we decided that the Plan does not have to pay for codes 95907, 95886, and 
95937 billed for date of service July 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6534 that 
were issued on August 22, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that you are asking for review and to 
reconsider payment. The Plan denied your request. The Plan says you do not have a qualifying wound for 
coverage of compression stockings. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6534 that were issued on August 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on July 20, 
2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that this should be included 
with your annual physical. 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 $10 
copayment for laboratory tests that are not FIT tests. 
 
You have been asked to pay a $10 copayment for the laboratory services. This item/service falls within the 
laboratory tests that are not FIT tests 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. Please note that laboratory services go beyond the scope of an annual physical, 
and are subject to separate cost sharing. Therefore, we decided that the Plan does not have to waive the 
copayment for the laboratory services provided on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on August 1, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you thought this would be covered in 
full. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $195 copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay the allowed amount of $130.02 which is less than the $195 copayment for a CT 
scan. This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a computed tomography (CT) 
scan provided on August 1, 2022.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 appears to be responding to treatment but is still unstable and requires 
additional short-term acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.