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

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
March 23, 2022, to March 25, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you believe your insurance 
should cover this. 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 $390 
copayment per day for days 1 through 5 and $0 after day 5.  
 
You have been asked to pay $390 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 March 23, 2022, to March 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel testing provided on February 14, 2022. 
 You asked the Plan to pay for the testing services. You say that all services were properly ordered. The Plan 
denied your request. The Plan says a panel test must not be unbundled. 
 
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 the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the respiratory panel testing provided on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided by a 
participating provider on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay the dentist. 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 20, 2021. Therefore, we decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided by a 
participating provider on May 24, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on August 9, 2021. 
 
You asked the Plan to pay for the rest home visit. The Plan denied your request. The Plan says original 
Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on May 24, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you only received 
medication and was not tested, the medication led to other problems so it 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 $35 
copayment per visit to a specialist.  
 
You have been asked to pay $35 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors 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 visit provided on May 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on February 
23, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that if you would have known the 
cost you wouldn't have gone. 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 $125 
copayment for all other outpatient services not provided in an ambulatory surgical center. 
 
 
 
 
 You have been asked to pay $125 copayment 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 copayment for outpatient surgery provided 
on February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve miscellaneous continuous positive airway pressure 
(CPAP) supplies (E1399). 
 
You asked the Plan to pre-approve miscellaneous CPAP supplies. You say that you need the requested supplies 
due to medical necessity. The Plan denied your request. The Plan says you do not specify what supplies are 
needed. There is no signed order by the provider for the requested equipment. There are no progress notes from 
the provider showing interval history or need or the necessity of supplies relative to your use. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The records show that you have not specified 
what supplies are needed and the provider did not sign an order or request specific supplies needed. The record 
also shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pre-approve miscellaneous continuous positive airway 
pressure (CPAP) supplies (E1399).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
January 9, 2022. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says the cost share was 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 $225 for 
ambulance transportation.  
 
You have been asked to pay $225 for ambulance transportation. Ambulance transportation falls within the 
Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance 
transportation provided on January 9, 2022.  
 Your complaint about the age of the truck and the uncomfortable ride is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an office visit and x-rays provided on 
March 25, 2022. 
 
You asked the Plan to waive the copayments for an office visit and x-rays. You say that you shouldn't have 
three separate copayments. The Plan denied your request. The Plan says the copayment 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 $15 
copayment for each x-ray and $40 copayment for each visit to a specialist.  
 
 
 You have been asked to pay a total of $70 copayment for an office visit and x-rays. X-rays fall within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The office visit falls 
within the Physician/Practitioner Services, Including Doctors 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 an office visit and x-rays provided on March 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mammogram provided on February 7, 
2022. 
 
You asked the Plan to waive the copayment for a mammogram. You say that this was your second 
mammogram, and it should be covered under the first. 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 $150 
copayment for Medicare covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
 
 
 You have been asked to pay $150 copayment for a mammogram. Mammograms 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 a mammogram provided on February 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy provided on February 1, 
2022. 
 
You asked the Plan to waive the copayment for radiation therapy. You say that you were told not to pay this 
bill. 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 $60 
copayment for each Medicare-covered radiation therapy service.  
 
You have been asked to pay $60 copayment for radiation therapy. Radiation therapy 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 radiation therapy provided on February 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the debridement of subcutaneous tissue 
provided on December 16, 2021. 
 
You asked the Plan to waive the copayment for the debridement services. You say that outpatient hospital stay 
should not be applied to very often repeated procedures like in your case. 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 $200 
copayment for each outpatient hospital visit.  
 
You have been asked to pay a $200 copayment for an outpatient hospital visit for the debridement services. The 
debridement services 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 copayment 
for the debridement of subcutaneous tissue provided on December 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration 
stating a delay in transferring the enrollee to an LTACH will prevent them from reaching their full potential. 
You say that the enrollee exceeds the Medicare established criteria for LTACH.  The Plan denied your request. 
The Plan says based on Medicare guidelines, the long-term acute care services you are requesting do not meet 
the requirements for approval. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan. The Plan has approved ongoing care in the current 
acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a continuous glucose monitor provided 
January 22, 2022, to March 22, 2022. 
 
You asked the Plan to waive the coinsurance for a continuous glucose monitor. You say that you are receiving 
bills even though you were told you would not have to pay, and you cannot afford to pay this. The Plan denied 
your request. The Plan says the cost share was 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 a continuous glucose monitor.  
 
You have been asked to pay $161.88 for 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 provided January 22, 2022, to March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on January 6, 2022. 
 
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on January 6, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visit provided on April 25, 2022. 
 
You asked the Plan to waive the deductible for office visit. You say that this should be covered. The Plan 
denied your request. The Plan says the deductible 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 $1000 deductible which applies to Physician/Practitioner Services, 
Including Doctors Office Visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services, Including Doctors Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $1000 deductible which applies to Physician/Practitioner 
Services, Including Doctors Office Visits. This cost sharing is a contractual obligation that had not been met at 
the time office visit was received on April 25, 2022. Therefore, we decided that the Plan does not have to waive 
the deductible for office visit provided on April 25, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services provided on 
February 13, 2022. 
 
You asked the Plan to pay for the hospital discharge services. The Plan denied your request. The Plan says 
original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital discharge day management services provided on 
February 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial psychiatric hospitalization. 
 
You asked the Plan to pre-approve partial psychiatric hospitalization. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve partial psychiatric hospitalization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that you do not appear to require partial hospitalization treatment as you 
were not showing any psychological or psychiatric illness and do not require this intensity of treatment. Based 
upon review the records provided, you do not meet the criteria for treatment at partial hospitalization level of 
care and could have been treated in a lesser restrictive setting as you were not showing any suicidal or 
homicidal ideation and were not showing any psychosis or aggressive behaviors. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of partial psychiatric hospitalization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve partial psychiatric hospitalization.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humulin R. 
 
You asked the Plan to pre-approve Humulin R. You say that the enrollee has been on Humulin R and Humulin 
N and has done well. The Plan denied your request. The Plan says Humulin R is not a covered benefit under the 
Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. 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 pre-approve Humulin R.  
 
Benefits for Humulin R may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic panel testing provided on December 23, 2021. 
 
You asked the Plan to pay for the testing services. You say that the treatment sought was medically necessary 
for the enrollee. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 one single code was not billed for the panel as required. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the genetic panel testing provided on December 23, 2021.