Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally-invasive sacroiliac spinal fusion (27279). 
 
You asked the Plan to pre-approve the minimally-invasive sacroiliac spinal fusion. You say that the service is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that minimally-invasive surgical (MIS) fusion of the 
sacroiliac (SI) joint is considered medically necessary when the patient has moderate to severe pain with 
functional impairment and pain persists despite a minimum six months of intensive nonoperative treatment that 
must include medication optimization, activity modification, bracing, and active therapeutic exercise targeted at 
the lumbar spine, pelvis, SIJ and hip including a home exercise program. 
 
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 minimally-invasive sacroiliac spinal 
fusion. Our reviewer says that this procedure is not medically necessary. Our physician reviewer found there is 
no documentation of at least 75% pain reduction with previous sacroiliac joint injections. More conservative 
measures are needed. 
 
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 minimally-invasive sacroiliac spinal fusion have not been met. Therefore, 
we decided that the Plan does not have to pre-approve minimally-invasive sacroiliac spinal fusion (27279).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility (SNF) stay provided on August 5, 
2021, to August 13, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the SNF stay. You say that the service provided to the enrollee was medically 
necessary. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider 
and the provider failed to get an approved authorization for the dates of service. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a skilled nursing facility (SNF) stay provided on 
August 5, 2021, to August 13, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for hyperbaric oxygen chamber services 
provided from September 2, 2021, to September 30, 2021. 
 
You asked the Plan to waive the copayments for the hyperbaric oxygen chamber services. You say that the 
services should be paid as in-network. 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 $400 
copayment for surgery or other services provided to you at an outpatient hospital.  
 
The file shows that you had a total of 17 visits. You have been asked to pay a $400 copayment for the first 3 hyperbaric oxygen chamber service visits. On your fourth visit, you reached your maximum out-of-pocket 
(MOOP) expenses for the year, resulting in the reduced copayment of $28.47. The total for the services is 
$1,228.47. The hyperbaric oxygen chamber services fall 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 copayments for hyperbaric oxygen chamber services provided from 
September 2, 2021, to September 30, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
November 2, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you cannot afford to pay 
the copayment. The Plan denied your request. The Plan says the proper copayment amount was 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 $120 
copayment for Emergency Services and Emergency Room.  
 
  You have been asked to pay a $120 copayment for an emergency room visit. An emergency room visit falls 
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. Therefore, we decided that the Plan does not have to waive the copayment for an 
emergency room visit provided on November 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services provided 
from November 15, 2021, to November 18, 2021. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you only 
changed rooms and had one single hospital stay. 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 $385 per 
day for days 1-5 and $0 after day 5 for each inpatient stay. Transfers to another level of care is considered a 
new admission.  
 The file shows that you were transferred from inpatient care to rehabilitation care on November 15, 2021. This 
transfer is considered a new admission, but there is no copayment for the discharge date. Therefore, you have 
been asked to pay $385 per day for the first 3 days of inpatient rehabilitation services. The total for this stay is 
$1,155 ($385 copayment x 3 days = $1,155). The inpatient rehabilitation services fall 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 rehabilitation 
services provided from November 15, 2021, to November 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lipectomy (15878, 15836). 
 
You asked the Plan to pre-approve the lipectomy. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 the lipectomy. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has congenital unilateral lymphedema. The record does 
not indicate that there is functional impairment.  
 
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 lipectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lipectomy (15878, 15836).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit (99342) provided on November 7, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the member does not have out-of-network benefits, and there is no 
documentation showing this member was referred to this non-contracted provider by a contracted provider. The 
Plan also says that there was also no indication that any attempt was made to obtain prior authorization for the 
out-of-network services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home visit (99342) provided on November 7, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 3, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that it was medically necessary to provide the 
treatment and would like the claim to be reprocessed for payment. The Plan denied your request. The Plan says 
the rendering provider is an out-of-network provider and there was no referral from an in-network provider or 
an approved authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 3, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an appendectomy provided on February 
25, 2020. 
 
You asked the Plan to waive the coinsurance for an appendectomy. You say that you never received any further 
notice that payment was due on this appendectomy until recently. You also say that you should not still owe 
money on this service since it has been more than a year since you had it done. 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 15% 
coinsurance for in-network outpatient surgery at an ambulatory surgical center.  
 
 You have been asked to pay $103.32, which is 15% of the allowed amount for an appendectomy ($688.77 
allowed amount x 15% coinsurance = $103.32). An appendectomy 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 coinsurance for an appendectomy provided on February 25, 
2020.  
 
Your complaint about receiving the bill more than a year after the service 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tracheal catheter supplies provided on December 20, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the tracheal catheter supplies. You say that you are appealing the denial. The 
Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for tracheal catheter supplies provided on December 20, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on September 22, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that it is the responsibility of the facility to get 
the authorization and the treatment you provided was medically necessary. The Plan denied your request. The 
Plan says the rendering provider is an out-of-network provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for nursing facility care provided on September 22, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Therapeutic Radiology on November 4, 
2021. 
 
You asked the Plan to waive the coinsurance for Therapeutic Radiology. You say that you already met your 
out-of-pocket maximum in 2021 therefore you should not be responsible for the cost share applied to the claim. 
The Plan denied your request. The Plan says the 20% coinsurance 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 20% 
coinsurance for Therapeutic Radiology. The total allowed amount is $543.34 and normally the coinsurance 
would be ($543.34 x 20% = $108.67).  However the charge is only $47.24 because thats when the $1,100 
maximum out-of-pocket amount and cost-sharing stops. 
 
You have been asked to pay 20% coinsurance for Therapeutic Radiology. Therapeutic Radiology 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 coinsurance for 
Therapeutic Radiology on November 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Magnetic Resonance Imaging (MRI) provided on October 
29, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a Magnetic Resonance Imaging (MRI). You say that you are requesting a 
reconsideration of the denial. The Plan denied your request. The Plan says The non-urgent services are not 
authorized because the provider is a non-network provider with the members health plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a Magnetic Resonance Imaging (MRI) provided 
on October 29, 2021 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 durable medical equipment (DME) 
provided on September 21, 2021. 
 
You asked the Plan to waive the coinsurance for the DME. You say that you have never used this product and 
they gave it to you for surgery, but it was the wrong product. The Plan denied your request. The Plan says the 
product was the correct according to the prescription and the proper coinsurance was 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 durable medical equipment, oxygen/ oxygen equipment and related supplies. The total amount 
allowed was $124.75 with a coinsurance of $24.95 ($124.75 total amount x 20% coinsurance). 
 
  You have been asked to pay a $24.95 coinsurance for the DME. The DME falls within 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 durable medical equipment (DME) provided on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 27, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the claim was submitted timely and should be 
processed. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on July 27, 2021, 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 the injection and an x-ray provided by a 
network physician on October 4, 2021. 
 
You asked the Plan to waive the copayment the injection and the x-ray. You say that you were not notified of 
the change to your insurance. You say you had this in the past and did not need authorization. The Plan denied 
your request. The Plan says you have been asked to pay the correct cost-sharing amount. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each Medicare-covered visit with an in-network specialist and a $20 copayment per day, per 
provider, for in-network Medicare-covered x-ray services.  
 
You have been asked to pay a $40 copayment for the injection and a $20 copayment for and the x-ray. The 
injection falls within the Physician/Practitioner services, including doctors office visits benefit category.  
The x-ray 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 the injection and an x-ray provided by a network physician on 
October 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from November 1, 2021, to November 29, 2021. 
 
You asked the Plan to waive the copayments for the PT services. You say that you were not aware of any 
copayments and you feel it should be covered. 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 $30 
copayment per day for therapy visits.  
 
The file shows you had a total of 9 PT visits from November 1, 2021, to November 29, 2021. Therefore, you 
have been asked to pay a $30 copayment for each of the PT services. The total for all visits is $270 ($30 copayment x 9 visits = $270). The PT services fall 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 copayments for physical therapy (PT) services provided from 
November 1, 2021, to November 29, 2021.