Persius/hicric huggingface dataset:
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 enrollee has reached the maximum level of 
recovery that she can expect to achieve in the current environment. The Plan denied your request. The Plan 
says authorization denied because 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 the enrollee's medical problems are stable, and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. 
 
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: 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 you had spinal surgery and have not walked in eight 
months. You say physical therapy is very important so you can do day-to-day activities. The Plan denied your 
request. The Plan says authorization denied because the IRF care is not medically necessary, and your needs 
can be met at a lower level of care such as a 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 your medical problems are stable, and there are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on February 18, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you are being charged more than 
whats on your card. 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 $105 
copayment for Medicare covered radiological diagnostic services not including x-rays, performed in a 
physicians office or free-standing facility.  
 
You have been asked to pay $96.58 which is less than the standard $105 copayment for an ultrasound. 
Ultrasounds fall 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 provided on 
February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you have an aggressive form of cancer, and you 
trust the team of doctors you work with at this facility. You also say that your oncologist is the one who 
referred you to the requested provider for treatment. The Plan denied your request. The Plan says there is an in-
network provider available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. The record shows that the enrollee now has an appointment 
scheduled with an in-network provider. Therefore, we decided that the Plan does not have to pre-approve an 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a continuous glucose monitor from 
February 8, 2022, to March 15, 2022. 
 
You asked the Plan to waive the coinsurance for a continuous glucose monitor. You say that you cannot afford 
to pay this coinsurance. The Plan denied your request. The Plan says the cost share has been applied 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 Durable Medical Equipment (DME) and Related Supplies.  
 
You have been asked to pay a $93.84 ($46.92 x 2 = $93.84) coinsurance for a continuous glucose monitor. A 
continuous glucose monitor falls 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 a continuous glucose monitor from February 
8, 2022, to March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete maxillary dentures (D5110) and partial 
mandibular dentures (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures accidentally got thrown 
away in the hospital. The Plan denied your request. The Plan says your benefit for the requested items or 
services 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 items or services was exhausted on date of service July 13, 2021. 
Therefore, we decided that the Plan does not have to pre-approve complete maxillary dentures (D5110) and 
partial mandibular dentures (D5214).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray provided on May 24, 2022. 
 
You asked the Plan to waive the copayment for x-ray. You say that this should be covered in full under your 
plan. 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 $100 
copayment for basic radiological services performed at an outpatient hospital.  
 
You have been asked to pay $79.43 which is less than the standard $100 copayment for x-ray. X-rays fall 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for x-ray provided on May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ECG provided on March 4, 2022. 
 
You asked the Plan to waive the copayment for ECG. You say that you never had to pay for this test before and 
you shouldn't have to now. 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 $25 
copayment for Medicare-covered non radiological diagnostic services.  
 
You have been asked to pay $17.76 which is less than the standard $25 copayment for ECG. ECG 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 ECG provided on March 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for cataract surgery provided on March 29, 
2022, and April 12, 2022. 
 
You asked the Plan to reduce the cost share for cataract surgery. You say that you didn't know it was going to 
be such a large bill you thought most of it would be covered. The Plan denied your request. The Plan says the 
cost share applied is correct. 
 
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 there is $450 deductible which applies to Outpatient Surgery Including Services 
Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers.  
 
The item or service you asked the Plan to reduce the cost share for falls within the benefit category Outpatient 
Surgery Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is $450 deductible which 
applies to Outpatient Surgery Including Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers. This cost sharing is a contractual obligation that had not been met at the time cataract surgery 
was received on March 29, 2022, and April 12, 2022. Therefore, $450 has been applied to meet the deductible.  Since the $450 deductible was met, you have also been asked to pay 10% coinsurance for the cataract surgery. 
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 the 
Plan does not have to reduce the cost for cataract surgery provided on March 29, 2022, and April 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
January 23, 2022, to January 28, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you never had a 
copayment before for inpatient care. 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 $250 
copayment per day for days 1 through 3.  
 
You have been asked to pay $750 ($250 x 3 days) copayment for inpatient hospital stay. Inpatient hospital stay 
falls within the Inpatient Hospital-Acute 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 inpatient hospital stay provided from January 23, 2022, to January 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy (97124). 
 
You asked the Plan to pre-approve massage therapy. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services at issue are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy (97124).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $40 copayment for laboratory services received on 
December 16, 2021. 
 
You asked the Plan to waive the $40 copayment for laboratory services. You say that it was your understanding 
that the laboratory services would be included with the doctor's visit when it was ordered therefore, you should 
not be responsible for this copayment. The Plan denied your request. The Plan says the cost share has been 
applied 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 $40 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $40 copayment for laboratory services. Laboratory services fall 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 $40 copayment for laboratory services received 
on December 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for SNF care and skilled services can be 
provided on an intermittent outpatient basis, in a long-term care facility, or at home with home health services. 
 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 pre-approve SNF care. Our reviewer says SNF care 
is not medically necessary. Our physician reviewer found that the enrollee does not have daily skilled nursing 
or therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional. Our 
physician reviewer found that the enrollee's needs can be provided at a lower level of care such as at home with 
home health services or in a long-term care 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out of network outpatient surgery 
provided on December 7, 2021. 
 
You asked the Plan to waive the coinsurance for outpatient surgery. You say that the surgery center is in 
network now and would like to be charged the in-network rate. 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 40% 
coinsurance for surgery performed at an out of network outpatient hospital facility or ambulatory surgical 
center.  
 
 
 
 You have been asked to pay $3,273.89 which is 40% of the allowed amount for outpatient surgery. Outpatient 
surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for out of 
network outpatient surgery provided on December 7, 2021.
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 you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
services you are requesting do not meet the requirements for approval. 
 
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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for surgical repair of a femur fracture after a fall. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
January 8, 2022, to January 12, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that the fear of contracting 
COVID-19 has been very overwhelming and now that you are recovering from COVID-19 it should be covered 
in full. 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 $250 
copayment for each day for days 1 through 5.  
 
 
 
 You have been asked to pay $1,000 (4 days x $250) copayment for inpatient hospital stay. Inpatient hospital 
stay 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 inpatient hospital stay provided from January 8, 2022, to January 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency services or pay for the self-
administered drugs provided on March 22, 2022.  
You asked the Plan to waive the copayment for the emergency services and to pay for the self-administered 
drugs. You say that you would like this charge to be covered. The Plan denied your request. The Plan says the 
copayment amount you are being charged for the emergency services is correct. The Plan also says that self-
administered drugs are not covered while you are in the hospital. 
 
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 $90 
copayment for Emergency care. The rules also say that Medicare Part B generally does not pay for self-
administered drugs.  
 
You have been asked to pay a $90 copayment for the emergency services. Emergency services fall within the 
Emergency 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. The self-administered drugs requested here are not among the types which are covered by Medicare 
Part B. Therefore, we decided that the Plan does not have to waive the copayment for the emergency services 
or pay for the self-administered drugs provided on March 22, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.