Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the PT visit provided on February 22, 2022. 
 
You asked the Plan to waive the copayment for the PT visit. You say that this charge does not seem fair. The 
Plan denied your request. The Plan says the copayment 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 $25 
copayment for physical therapy services.  
 
You have been asked to pay $25 for the PT visit. The PT visit falls within the Outpatient Rehabilitation 
Services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the physical therapy (PT) 
visit provided on February 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says the long-term acute care hospital (LTACH) 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 There is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. 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 health plan. 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the segmental gradient pneumatic appliance (E0673x2) 
provided December 9, 2021. 
 
You asked the Plan to pay for a pneumatic appliance. You say that the DME equipment was prescribed by the 
doctor and was issued to the enrollee during their surgery. You are not contracted with the facility or the 
prescribing physician and do not receive payment from either provider. The Plan denied your request. The Plan 
says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. The enrollee used the equipment in the facility during and/or after 
surgery. Payment for this service would have been included under the facility claim. Payment for this service is 
the responsibility of the facility or hospital that provided the surgery. Based on this information we decided that 
Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of 
Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of 
peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan 
does not have to pay for the segmental gradient pneumatic appliance (E0673x2) provided December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve apicoectomy (D3410), guided tissue regeneration 
(D4266), bone graft (D3428), biologic materials to aid in soft and osseous tissue regeneration (D3431) and 
collection and application of autologous blood concentrate product (D7921) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee cannot pay for treatment and is at 
risk of infection. The Plan denied your request. The Plan says that these services are not covered. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
apicoectomy (D3410), guided tissue regeneration (D4266), bone graft (D3428), biologic materials to aid in soft 
and osseous tissue regeneration (D3431) and collection and application of autologous blood concentrate 
product (D7921) for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for elective cardioversion on February 10, 
2022. 
 
You asked the Plan to waive the copayment for elective cardioversion. You say that you would like to appeal 
the cost share. 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 a $350 
copayment for elective cardioversion.  
 
You have been asked to pay a $350 copayment for elective cardioversion. elective cardioversion 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 elective cardioversion on 
February 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for breathing test provided on February 28, 
2022. 
 
You asked the Plan to waive the copayment for breathing test. You say that you never saw your doctor this day 
so the charge should be waived. 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 $90 
copayment for breathing capacity tests.  
 
 
 
 
 
 You have been asked to pay $90 copayment for breathing test. Breathing tests 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 breathing test provided on February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on 
January 24, 2022. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the providers rely on facility staff 
to verify eligibility and obtain authorization from the patients insurance company. The Plan denied your 
request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior 
authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit and eye tests provided on 
February 21, 2022. 
 
You asked the Plan to waive the copayment for the office visit and eye tests. You say that you have the same 
exam done every year and don't have to pay a copayment. You say that the only thing you pay the provider is 
$35 for the office visit. The Plan denied your request. The Plan says the copayments 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 $35 
copayment for services received from a Level 1, in-network specialist physician and a $75 copayment for 
diagnostic procedures and tests, including ultrasounds, at all in-network locations of service. 
  You have been asked to pay a $35 copayment for the office visit. You have also been asked to pay a $40 
copayment for the eye tests, which is less than the standard $75 copayment. The office visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category. The eye tests fall within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. Outpatient diagnostic tests 
are considered a separate service. 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 office visit and 
eye tests provided on February 21, 2022.
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 does not require the 
intensive rehabilitation therapy program provided in an 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $99.60 copayment for an ultrasound performed on January 
7, 2022. 
 
You asked the Plan to waive the $99.60 copayment for an ultrasound performed on January 7, 2022. You say 
that you should not have to pay this as it was an extension of a previous screening. The Plan denied your 
request. The Plan says you are responsible to pay a $100 copayment for an ultrasound. 
 
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 $100 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $99.60 copayment for an ultrasound. An ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plans allowance for this service 
was $99.60. Since the allowed amount is less than the contracted cost share, you are only being asked to pay 
the lower amount. 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 $99.60 copayment for an ultrasound performed 
on January 7, 2022.
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days 
a week, or 15 hours over seven consecutive days. You are completing hygiene tasks with set up assistance. You 
require minimum assistance with transfers and can ambulate 60 feet with a platform walker requiring contact 
guard assistance. You have had a functional decline from your baseline level of function and may benefit from 
therapy. However, it is unlikely that you can participate in and benefit from the intensity of therapies provided 
on acute inpatient rehabilitation. A therapy note dated 7/26/2022 indicated that you declined to participate in 
therapy and wanted to rest. You were also noted to be confused at times and inconsistent with following 
commands during therapy. 
 
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 to the enrollee from January 
28, 2022, to February 24, 2022. 
 
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 submitted plan of care does not contain the required date of the physician's signature, and is 
therefore not valid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The provider's signature is not valid for this claim, as it is not dated. The services cannot be verified. 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 home health services provided to the enrollee from January 28, 
2022, to February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing laboratory services (80321, 80323, 80324, 
80332, 80335, 80338, 80342, 80345, 80346, 80348, 80349, 80353, 80354, 80355, 80356, 80357, 80358, 80359, 
80360, 80364,80365, 80366, 80368, 80369, 80372, 80373, 80375) provided on December 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says these services are not valid for payment 
under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that CTP codes 80320  80377 are non-covered by 
Medicare. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for drug testing laboratory services 
(80321, 80323, 80324, 80332, 80335, 80338, 80342, 80345, 80346, 80348, 80349, 80353, 80354, 80355, 
80356, 80357, 80358, 80359, 80360, 80364,80365, 80366, 80368, 80369, 80372, 80373, 80375) provided on 
December 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $976.43 coinsurance for a prosthesis provided on March 9, 
2022. 
 
You asked the Plan to waive the $976.43 coinsurance for a prosthesis provided on March 9, 2022. You say that 
you have never had to pay such a high amount. The Plan denied your request. The Plan says the $976.43 
coinsurance has been correctly applied. 
 
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 Prosthetic Devices and Related Supplies.  
 
You have been asked to pay a $976.43 coinsurance for a prosthesis provided on March 9, 2022. A prosthesis 
falls within the Prosthetic Devices 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 $976.43 coinsurance for a prosthesis provided on March 9, 2022.  
 PROCEDURE AMOUNT BILLED PLAN ALLOWANCE MEMBER 
RESPONSIBILTIY 
L5950 $567.67 $567.67 $113.53 
L5624 $263.14 $263.14 $52.63 
L5650 $353.32 $353.32 $70.66 
L5631 $318.02 $318.02 $63.60 
L5649 $1,146.34 $1,146.34 $229.27 
L5651 $869.21 $869.21 $173.84 
L5671 $416.19 $416.19 $83.24 
L5673 $948.32 $948.32 $189.66 
TOTALS $4882.21 $4882.21 $976.43
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is the best medication for the enrollee. The Plan 
denied your request. The Plan says that this is not covered under Part B. 
 
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 Dupixent for the enrollee.  
 
Benefits for this drug 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for medical supplies provided January 19, 
2022, to March 21, 2022. 
 
You asked the Plan to waive the coinsurance for medical supplies provided January 19, 2022, to March 21, 
2022. You say that you have not previously had to pay a copayment for these same services. The Plan denied 
your request. The Plan says you are responsible to pay a $33.34 coinsurance for medical supplies provided 
January 19, 2022, to March 21, 2022. 
 
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 Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
  
DOS SERVICE/CPT AMOUNT 
BILLED 
AMOUNT 
ALLOWED 
PLAN PAID COINSURANCE 
01/19/2022 A4369 $4.32 $4.32 $3.46 $0.86 
01/19/2022 A6216 $2.00 $2.00 $1.60 $0.40 
01/19/2022 A6402 $6.00 $6.00 $4.80 $1.20 
01/19/2022 A6252 $44.70 $44.70 $35.76 $8.94 
02/21/2022 A4369 $4.32 $4.32 $3.46 $0.86 
02/21/2022 A6216 $2.00 $2.00 $1.60 $0.40 
02/21/2022 A6252 $44.70 $44.70 $35.76 $8.94 
02/21/2022 A6402 $6.00 $6.00 $4.80 $1.20 
03/21/2022 A6216 $2.00 $2.00 $1.60 $0.40 
03/21/2022 A6252 $44.70 $44.70 $35.76 $8.94 
03/21/2022 A6402 $6.00 $6.00 $4.80 $1.20 
TOTALS  $166.74 $166.74 $133.40 $33.34 
 
You have been asked to pay a $33.34 coinsurance for medical supplies. Medical supplies 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 coinsurance for medical supplies provided January 19, 2022, to March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 25, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. In this case, this means that the professional interpretation must be 
billed with modifier -26 for payment to be considered. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for the lab services provided on June 25, 2021.