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 care provided from 
December 17, 2021, to December 29, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were informed that there 
were no copayments for COVID-19 hospital stays. The Plan denied your request. The Plan says you were 
charged this cost sharing 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 $300 per 
day for days 1-5 and $0 per day for additional days for each inpatient stay.  
 
The file shows that you were in the hospital from December 17, 2021, to December 29, 2021. Therefore, you 
have been asked to pay $300 per day for days 1-5 of inpatient care, for a total of $1,500. Please note that the 
Plan's COVID-19 cost share waivers ended on February 28, 2021. The inpatient care 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 care 
provided from December 17, 2021, to December 29, 2021.
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 care will help the enrollee 
regain a maximum state of health and function. The Plan denied your request. The Plan says under Medicare, 
LTACH care is not medically necessary because your records show you no longer require services which can 
only be given in a hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be administered at the current facility. The enrollee 
does not require services at the LTACH that are not already available at the current facility. Transfer to the 
LTACH is not medically necessary as it would not be clinically advantageous. Completion of treatment at the 
current facility is recommended. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on May 23, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that the copayment should be $50. The 
Plan denied your request. The Plan says the cost sharing you are being charged 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 $55 
copayment of the total cost for Medicare-covered services provide by other health care professionals such as 
nurse practitioners, physicians assistants, etc. covered services include medically necessary medical care or 
surgery services furnished in a physicians office, certified ambulatory surgical center, hospital outpatient 
department, or any other location. 
 
 
 
 
 You have been asked to pay a $55 copayment for office visit. 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 office visit on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a surgical wound care visit provided on 
March 24, 2022. 
 
You asked the Plan to waive the copayment for a surgical wound care visit. You say that the visits were 
medically necessary and appear to be a simple task. You say that you did not expect to pay and believes the 
Plan should cover the payment. 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 $395 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay $191.10 for surgical wound care, which is less than the standard $395 copayment. 
A surgical wound care visit falls within the Outpatient Surgery and Other Medical 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 a surgical wound care visit provided on March 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Out-of-Network computed tomography 
(CT) scan provided on June 24, 2022. 
 
You asked the Plan to waive the copayment for an Out-of-Network CT scan. You say that you should not be 
responsible for this copayment, as you cannot get the CT scan read now. The Plan denied your request. The 
Plan says you were charged this cost sharing 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 $50 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $50 copayment for an Out-of-Network CT scan. An Out-of-Network CT scan 
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 an Out-of-Network computed 
tomography (CT) scan provided on June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a surgical wound care visit provided on 
March 31, 2022. 
 
You asked the Plan to waive the copayment for a surgical wound care visit. You say that the visits were 
medically necessary and appear to be a simple task. You say that you did not expect to pay anything and 
believes the Plan should cover the payments. 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 $395 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay $191.10 for surgical wound care, which is less than the standard $395 copayment. 
Surgical wound care falls within the Outpatient Surgery and Other Medical 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 a surgical wound care visit provided on March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the DME provided on July 1, 2022. 
 
You asked the Plan to waive the coinsurance for the DME. You say that you received a copayment bill for 
crutches that you did not request or receive. You say that you informed the doctor of a scooter already owned 
and would be using. 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 in-network Medicare-covered DME item.  
 
You have been asked to pay a coinsurance of $8.80, which is 20% of the allowed amount for the DME ($44 
allowed x 20% = $8.80). DME 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 the DME provided on July 1, 
2022.  
 Your complaint about not requesting or receiving the crutches you signed for 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical (diagnostic) vision exam 
provided on May 3, 2022. 
 
You asked the Plan to waive the copayment for a medical (diagnostic) vision exam. You say that your eye 
doctor referred you to a specialist because he thought you were showing early signs of cataract. You say that 
you believe the appointment should have been billed to your vision insurance rather than your medical. 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 $45 
copayment for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye.  
 
 
  You have been asked to pay a $45 copayment for a medical vision exam. A medical vision exam falls within 
the Vision Care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a medical (diagnostic) 
vision exam provided on May 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan on April 
28, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 $100 
copayment for outpatient diagnostic radiology (CT, MRI, PET scan, etc). Covered services include but are not 
limited to other outpatient diagnostic tests. 
 
You have been asked to pay a $100 copayment for CT scan. CT scans 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 
computed tomography (CT) scan on April 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reacher/grabber device. 
 
You asked the Plan to pre-approve a reacher/grabber device. You say that this device is necessary due to your 
lost stretching flexibility. The Plan denied your request. The Plan says this item is a self-help item and is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a reacher/grabber device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on April 21, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 $35 
copayment for each in-person specialist visit. Covered services include consultation, diagnosis, and treatment 
by a specialist.  
 
You have been asked to pay a $35 copayment for office visit. 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 office visit on April 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 16, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment and supplies (A6450, A6446, 
A6199, A6212) (DME) provided on April 28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the durable medical equipment and supplies. You say that the items should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the items denied correctly 
as they were non-emergent and prior authorization was not obtained. 
 
  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 durable medical equipment and supplies (A6450, 
A6446, A6199, A6212) (DME) provided on April 28, 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 a surgical wound care visit provided on 
March 15, 2022. 
 
You asked the Plan to waive the copayment for a surgical wound care visit. You say that the visits were 
medically necessary and appear to be a simple task. You say that you did not expect to pay and believes the 
Plan should cover the payment. 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 $395 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  You have been asked to pay $191.10 for surgical wound care, which is less than the standard $395 copayment. 
A surgical wound care visit falls within the Outpatient Surgery and Other Medical 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 a surgical wound care visit provided on March 15, 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 enrollee currently meets LTACH 
admission criteria under the Centers for Medicare and Medicaid Services (CMS) guidelines. You also say that 
the enrollee's ongoing medical care warrants an LTACH level of care to achieve a "safe and sustainable 
discharge. The Plan denied your request. The Plan says the member is receiving appropriate in-patient acute 
care and does not require transfer to a Long-Term Acute Care Hospital (LTACH). 
 
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 appears to be stable and improving and should only require short-term 
additional acute care services that can safely be administered at the current facility until more stable and 
appropriate for a lower level of care. Our physician reviewer also found that the patient does not require 
services at the LTACH that are not already available at the current 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 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 pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this equipment is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage for a CGM have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).