Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a computed tomography (CT) scan and a 
follow up visit provided on June 29, 2022, and July 6, 2022. 
 
You asked the Plan to waive the copayments for a computed tomography (CT) scan and a follow up visit. You 
say that you are already on a payment plan with this facility and think these copayments should be applied to 
that. 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 $200 
copayment for outpatient diagnostic tests and therapeutic services and supplies, and a $10 copayment for 
Physician/practitioner services, including doctor's office visits. You have been asked to pay the allowed amount 
of $179.27 which is less than the $200 copayment for a CT scan + $10 = $189.27. 
 
 You have been asked to pay a $189.27 total copayment for outpatient diagnostic tests and therapeutic services 
and supplies, and Physician/practitioner services, including doctor's office visits for a computed tomography 
(CT) scan and a follow up visit. This item/service falls within the outpatient diagnostic tests and therapeutic 
services and supplies and 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 copayments for a computed tomography (CT) scan and a follow up visit 
provided on June 29, 2022, and July 6, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a specialist office visit provided on June 13, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not have to 
pay the copayment because you left prior to seeing the provider. The Plan denied your request. The Plan says 
that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $30 copayment for services received from a Level 1 
specialist physician.  
 
The Plan says you must pay a $30 copayment for a specialist office visit. Based on the medical records 
showing that you were not actually seen by the specialist physician, and the physician advising to not charge 
for the visit, you cannot be asked to pay for a copayment for this specialist office visit. Therefore, we decided 
that the Plan has to waive the copayment for a specialist office visit provided on June 13, 2022.  
 
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: 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 LTACH is medically necessary, and 
a lower level of care is unable to manage the enrollee's care. The Plan denied your request. The Plan says the 
LTACH is not medically necessary, and the enrollee's needs are being met at the current facility. 
 
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 in this case the enrollee was admitted with acute hypoxic respiratory failure in the 
setting of COVID-19 pneumonia. The record indicates that the enrollee is improving but still requires acute 
care services before transitioning to a lower level of care. The enrollee continues to receive acute care services, 
and these have not been denied. 
 
 
 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: 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 acute inpatient care is medically necessary. The 
Plan denied your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be 
met at a lower level of care such as 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 based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week 
of rehabilitative services with regular physician evaluation. The enrollees care needs can be met at 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 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve a complete mandibular denture (D5120). You say that you need your 
dentures replaced due to them being broken. You also say you are unable to eat regular food. The Plan denied 
your request. The Plan says that based on the members 2022 benefit package for dental service, this is not 
approved because the requested service, D5120 - Complete Denture  Mandibular with exceeds the maximum 
count allowed per period. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan failed to submit an Evidence of Coverage (EOC). Without a 2022 
Evidence of Coverage from the Plan, we are unable to verify that the denial is correct. Therefore, we decided 
that the Plan has to pre-approve a complete mandibular denture (D5120).  
 
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 office visit provided on June 13, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you are disputing the share cost. 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 $25 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $25 copayment for office visit. This item/service 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 office visit provided on June 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for premier test strips on September 26, 2022. 
 
You asked the Plan to waive the coinsurance for premier test strips. You say that you want to appeal the 
amount being charged. 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 Lifescan test strips, diabetic supplies and therapeutic shoes or inserts. Covered services include 
supplies to monitor your blood glucose: Blood glucose monitor, blood glucose test strips, lancet devices and 
lancets, and glucose-control solutions for checking the accuracy of test strips and monitors. The provider billed 
in the amount of $35.76 and the allowed amount is $29.13. The plan paid $23.67. $29.13 - $23.67 = $5.46. 
Therefore, results in the total cost sharing amount of $5.46. 
 
 
 
 You have been asked to pay a 20% coinsurance for premier test strips. This item/service falls within the 
Diabetes self-management training, diabetic 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 coinsurance for premier test strips on September 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for a computer tomography (CT) scan provided 
on August 3, 2022. 
 
You asked the Plan to lower the copayment for a CT scan. You say that you feel this should only be a $40 
copayment, not this $137.09. 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 $275 
copayment for outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay the 
allowed amount of $137.09 which is less than the $275 copayment for a CT scan. 
 
You have been asked to pay a $275 copayment for a CT scan. 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 lower the copayment for a computer tomography (CT) scan provided on 
August 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for medical eye exam provided on August 4, 
2022. 
 
You asked the Plan to waive the copayment for medical eye exam. You say that you are disputing the share 
cost. 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 $35 
copayment for vision care.  
 
You have been asked to pay $35 copayment for medical eye exam. This item/service falls within the vision 
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 medical eye exam provided on 
August 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services (A0999) provided on 
August 7, 2022. 
 
You asked the Plan to pay for the paramedic intercept services. You say that you think it is unfair that you are 
being charged for the staff that rode in the ambulance with you. The Plan denied your request. The Plan says 
this claim processed correctly according to the contract and Medicare guidelines, and there was no plan error.  
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services (A0999) provided on August 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), the 
bitewing x-rays (D0274), the panoramic x-ray (D0330), the cleaning (D1110), and the topical application of 
fluoride (D1206) provided by an out-of-network provider on September 27, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you could not find a network provider. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the comprehensive oral evaluation (D0150), 
the bitewing x-rays (D0274), the panoramic x-ray (D0330), the cleaning (D1110), and the topical application of 
fluoride (D1206) provided by an out-of-network provider on September 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says the 
requested bed is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
We looked at the file and the rules. While a total electric hospital bed may be appropriate in this case, neither 
the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-
approve a total electric hospital bed.
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 the enrollee will be able to tolerate the fifteen hours 
of therapy a week that is required at the inpatient rehab level of care so they can safely return home. You say 
that the enrollee's medical stability will require the close physician onsite to assess both their medical and 
functional progression. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee's needs can be met at an alternate level of care. 
 
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 the enrollee is medically stable and does not require close supervision for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. While the enrollee 
can benefit from physical and occupational therapy, their needs can be safely provided in an alternate level of 
care such as a skilled nursing 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the criteria has been met. The Plan 
denied your request. The Plan says that the admission to a 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 that the record indicates that the enrollee continues to require critical care services for 
hypotension requiring vasopressor support. The enrollee continues to receive acute care services, and these 
have not been denied. The medical record does not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied. 
 
 
 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a La-Z-Boy recliner. 
 
You asked the Plan to pre-approve a La-Z-Boy recliner. You say that the requested item is a medical necessity 
for you. The Plan denied your request. The Plan says rules for coverage for durable medical equipment have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a La-Z-Boy recliner.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection of hyaluronan. 
 
You asked the Plan to pre-approve hyaluronan. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the enrollee has been treated with corticosteroids that have been 
helpful. 
 
The Plan follows Medicare rules. Medicare rules state that injections of hyaluronan are only covered if certain 
criteria are met. 
 
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 hyaluronan. Our reviewer says that the 
enrollee does not meet the criteria for the requested use of hyaluronan. Our physician reviewer found 
hyaluronan is indicated for patients who have not responded to conservative nonpharmacological therapy or to 
analgesics or intra-articular glucocorticoid injections. The records submitted show that the enrollee has 
responded with great relief from intra-articular glucocorticoid injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyaluronan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an injection of hyaluronan.
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 the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee can get the services they need provided safely in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require intensive therapy or frequent physiatry oversight. 
 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.