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

 
We decided that the Plan does not have to waive the coinsurance for disposable medical supplies provided on 
March 28, 2022. 
 
You asked the Plan to waive the coinsurance for disposable medical supplies. You say that you used to pay less 
for these supplies, and you would like to pay what you used to pay. The Plan denied your request. The Plan 
says the coinsurance applied 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 20% 
coinsurance for each Medicare-covered durable medical equipment item.  
 
 
 
 
 
 You have been asked to pay $228.30 which is 20% of the allowed amount for disposable medical supplies. The 
allowed amount is $1,141.50 (20% x $1,141.50= $228.30). Disposable medical supplies fall within the Durable 
Medical Equipment (DME) and Related Supplies benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for disposable medical supplies provided on March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits provided on April 
29, 2022, and April 30, 2022. 
 
You asked the Plan to waive the copayments for the office visits. You say that you feel the office visit 
copayments should be included with the surgery copayment. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for services obtained from a specialist.  
 
You have been asked to pay a $40 copayment for each of the office visits, for a total of $80. The office visits 
fall 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 copayments for specialist office visits provided on April 29, 2022, and April 30, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
January 4, 2022. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you never asked the 
provider to call you and you would like the bill waived. The Plan denied your request. The Plan says the proper 
copayment was applied for the service that was rendered. 
 
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 per specialist telehealth visit (including eDerm).  
 
  You have been asked to pay a $30 copayment for the specialist telehealth visit. The specialist telehealth visit 
falls within the Telehealth Services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
specialist telehealth visit provided on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visit, an EKG and reading provided 
on January 10, 2022, and January 21, 2022. 
 
You asked the Plan to waive the copayments for office visit, EKG and reading.. You say that you shouldn't be 
charged this much. The Plan denied your request. The Plan says the copayments applied are 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 $35 
copayment for specialist office visits and $20 copayment for an EKG and the reading. 
 You have been asked to pay a total of $67.78 for the office visit, EKG and reading. The office visit falls within 
the Physician/Practitioner Services, Including Doctors Office Visits benefit category. The EKG and reading 
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 copayments for office visit, an EKG and reading provided on January 10, 
2022, and January 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intubation services (31500) provided to the enrollee on 
July 15, 2021. 
 
You asked the Plan to pay for these services. You say that the records support the services billed. The Plan 
denied your request. The Plan says that the claim denied as duplicate correctly. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 1, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the intubation services (31500) provided to the enrollee on 
July 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from November 1, 
2021, to November 10, 2021 
 
You asked the Plan to waive the copayment for SNF care. You say that this service should be covered. The 
Plan denied your request. The Plan says the copayment applied 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 $184 
copayment per day for days 21 through 45.  
 
You have been asked to pay $1,288 (7 days x $184) copayment for SNF care. SNF care 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. Therefore, we decided that the Plan does not have to waive the copayment for SNF care 
provided from November 1, 2021, to November 10, 2021
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjacent tissue transfer or rearrangement (procedure code 
14061) provided to the enrollee on October 15, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied procedure code was not supported by the medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 14061 is "Adjacent tissue transfer or rearrangement, 
eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm." 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the records do not support the use of 
CPT 14061 in this case. The operative report does not show that this procedure was rendered on the date of 
service. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for adjacent tissue transfer or rearrangement (procedure code 14061) provided to the enrollee on 
October 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) billed for date of service 
January 6, 2022. 
 
You asked the Plan to pay for critical care. You say that this service was billed appropriately. The Plan denied 
your request. The Plan says this service is not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported as billed. Specifically, the time spent providing this service is 
not noted in the medical record. Without this information, we cannot verify that 30-74 minutes of critical care 
were provided on the date in question. Based on this information, we decided that Medicare rules for coverage 
of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care, 
first hour (99291) billed for date of service January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 19, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services were not urgent or emergent. 
 
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 home health services provided on January 19, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy procedure and office visit provided on March 4, 
2022. 
 
You asked the Plan to pay for the therapy procedure and office visit. You say that you don't understand how 
your initial exam can't be covered when you can't be treated without one. The Plan denied your request. The 
Plan says only manual manipulation of the spine to correct subluxation is a covered chiropractic service and 
any other service is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the therapy procedure and office visit provided on March 4, 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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 services offered at the LTACH are available at the current acute care facility. The 
enrollee's needs are met in the current 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 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 conditions are stable on outpatient medications with no issues 
that appear to require a physicians evaluation three or more times per week. The enrollee will not be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. Provided records do not suggest that the enrollee is likely to make significant 
improvements in functional status in a reasonable amount of time to necessitate admission to an acute inpatient 
rehabilitation facility. Records do not clarify that treatment at the skilled nursing facility level is not appropriate 
in this case. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 16, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services were not urgent or emergent. 
 
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 home health services provided on March 16, 2022 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided on 
December 27, 2021, and January 3, 2022. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that the wounds were only 
wrapped and the cost of that is too high. The Plan denied your request. The Plan says the copayments applied 
are 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 $40 
copayments for each specialist office visits.  
 
You have been asked to pay $79.62 copayment for the specialist office visits. Specialist office visits fall 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 specialist office visits provided on December 27, 2021, and January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4-wheel drive, all-terrain motorized scooter. 
 
You asked the Plan to pre-approve 4-wheel drive, all-terrain motorized scooter. You say that you need this item 
in order to hunt, fish and feed your horses. The Plan denied your request. The Plan says that this item is 
considered a convenience item and therefore is non-covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve 4-wheel drive, all-terrain motorized scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic service provided on February 28, 2022, by an 
OON provider. 
 
You asked the Plan to pay for a chiropractic service. You say that you were uninformed of network issues at 
the time of the Plan enrollment date. The Plan denied your request. The Plan says the out-of-network services 
were not authorized. 
 
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 chiropractic service provided on February 28, 
2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three additional acupuncture treatments. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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. In this case, the documentation provided does not indicate that the requested services would be provided by a 
licensed acupuncturist who is under the supervision of a physician. As such, we have concluded that this 
request is not Medicare-covered and the supplemental benefit would 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 in this case. Our physician reviewer found that the records 
requested and provided by the practitioner do not support additional acupuncture therapies. The review has 
determined that three additional acupuncture treatments are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and the Plans rules. Based on this information, we decided that 
the Plans rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve three additional acupuncture treatments.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have \to waive the copayment for an urgent care visit provided on February 
1, 2022. 
 
You asked the Plan \to waive the copayment for the urgent care visit. You say that you were told there would 
be no copayment for the COVID test and would like the copayment to be waived. The Plan denied your 
request. The Plan says the COVID test was paid in full, and the proper copayment was applied for the service 
that was rendered. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each Medicare-covered urgent care facility visit. This copayment is not waived if you are 
admitted as an inpatient to the hospital within 24 hours for the same condition.  
 
  You have been asked to pay a $50 copayment for the urgent care visit. The urgent care visit falls 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 copayment for an urgent 
care visit provided on February 1, 2022.