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

 
We decided that the Plan does not have to waive the deductible for a diagnostic mammogram provided on 
December 15, 2021. 
 
You asked the Plan to waive the deductible for a diagnostic mammogram. You say that this was scheduled for 
a screening mammogram. 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. Your 
contract with the Plan says that there is $395 deductible which applies to a diagnostic mammogram.  
 
The medical record shows that you had complaints of breast pain at an office visit with your gynecologist 
resulting in a diagnostic mammogram. The diagnostic mammogram you asked the Plan to waive the deductible 
for falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is $395 deductible which 
applies to a diagnostic mammogram. This cost sharing is a contractual obligation that had not been met at the time a diagnostic mammogram was received on December 15, 2021. Therefore, we decided that the Plan does 
not have to waive the deductible for a diagnostic mammogram provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 17, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that the drive through center you 
went to was closed so you had to go to urgent care. The Plan denied your request. The Plan says the copayment 
applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $30 
copayment for Urgently needed services.  
 
 You have been asked to pay $30 copayment for an urgent care visit.  The urgent care visit falls within the 
Urgently needed 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 an urgent 
care visit provided on January 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from January 22, 2022, to January 24, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that the services should be covered. The 
Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
drugs you received are not covered under Medicare 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 pay for the self-administered drugs 
provided in an outpatient setting from January 22, 2022, to January 24, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for cardiac rehabilitation services provided 
from May 10, 2021, to May 24, 2021. 
 
You asked the Plan to waive the copayments for the cardiac rehab. You say that you were informed that there 
would be no copayments for the services. 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 $20 
copayment per visit for cardiac rehabilitation services.  
 
The file shows that the Plan has reprocessed the claim to apply the correct cost sharing amounts. Therefore, 
you have been asked to pay a $20 copayment each of the 5 cardiac rehab visits, for a total of $100. The cardiac rehab falls within the Cardiac 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 cardiac rehabilitation services provided from May 10, 2021, to May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection services. 
 
You asked the Plan to pre-approve epidural steroid injection services. You say that this is medically necessary. 
The Plan denied your request. The Plan says the criteria for injection services have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that for epidural steroid injection services to be covered, 
the patient must not have major risk factors for spinal cancer. If cancer is present, the patient's pain must be 
clearly unrelated to the cancer diagnosis. 
 
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 epidural steroid injection services. Our 
reviewer says that the requested epidural injection services are not medically reasonable and necessary. Our 
physician reviewer found the enrollee is a 33-year-old woman has metastatic breast cancer with a presumed 
pathological fracture at S1. She is taking oxycodone and Lyrica for pain. In this case, there is no indication for 
an epidural steroid injection to treat pain associated with metastatic breast cancer to bone. The request is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injection services have not been met. 
 
 
  
 Therefore, we decided that the Plan does not have to pre-approve epidural steroid injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the debridement visits provided from 
November 1, 2021, to November 29, 2021. 
 
You asked the Plan to waive the copayment for the debridement visits. You say that you believe your visits 
could have been coded differently. 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 $225 
copayment per visit for outpatient surgery or procedures.  
 
You have been asked to pay a $900 ($225 copay x 4 visits) for the debridement visits. The debridement visits 
fall within the Outpatient Hospital 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 debridement visits provided from November 1, 2021, to November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the request for a home mechanical ventilator set in average volume-
assured pressure support (AVAPS) mode that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. This patient has severe COPD, documented 
on pulmonary function testing, with a history of frequent exacerbations. The patient was started on a home 
ventilator with AVAPS-AE following a hospitalization for respiratory failure in 2019 and is reportedly using it. The medical records provided do not document arterial blood gas findings, but the patient was described as 
having CO2 retention. The AVAPS-AE mode can be provided via BiPAP and it appears this has not been tried. 
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable 
ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the needle electromyography (95863) and 
the osteopathic manipulative treatment (98928) provided on June 15, 2021 and August 3, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 Medicare-covered non-
radiological diagnostic services. Additionally, you must pay a $30 copayment for services obtained from a 
specialist, or under certain circumstances, treatment by a nurse practitioner or physicians assistant or other 
non-physician health care professionals in a specialists office.  
 
You have been asked to pay $55 ($30 + $25) for the Medicare-covered non-radiological diagnostic service and 
the specialist service provided. 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 the needle 
electromyography (95863) and the osteopathic manipulative treatment (98928) provided on June 15, 2021 and 
August 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion surgery. 
 
You asked the Plan to pre-approve spinal fusion surgery. You say that you were told physical therapy would 
not help and that you can't have any more injections because the steroid shots are at the limit and are causing 
other issues. The Plan denied your request. The Plan says the requested procedure is not medically necessary. 
The Plan says that the enrollee has not failed 3 months of non-operative therapy including a full course of 
physical therapy. 
 
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 spinal fusion surgery. Our reviewer 
says that spinal fusion surgery is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is not a documented adequate trial and failure of physical therapy for back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal fusion surgery have not been met.  
  
 
Therefore, we decided that the Plan does not have to pre-approve spinal fusion surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the requested device would be used in a BiPAP mode that could be 
provided with a BiPAP (E0471) device with AVAPS- AE added to assure adequate tidal volumes. 
 The Plan must follow Medicare rules. The rules say that claims for ventilators used to provide CPAP or bi-level 
CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and necessary.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-
approve a portable ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 22, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollees physician sent the specimen to 
your laboratory to process, and you would like the claim paid. The Plan denied your request. The Plan says the 
rendering and referring providers are both OON providers and there was no 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 December 22, 
2021, by an out-of-network (OON) provider.
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. The Plan denied your request. The Plan says the enrollee is not 
able to take part in 3 hours of therapy a day. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for surgical repair of a femur fracture after a fall. His 
medical problems are stable. There is not a reasonable expectation that he will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. While he has a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging services (78452). 
 
You asked the Plan to pre-approve myocardial perfusion imaging services. You say that this imaging is 
medically reasonable and necessary. The Plan denied your request. The Plan says there is no documentation of 
an abnormal electrocardiogram or a medical reason why your needs cannot be met with an ordinary cardiac 
stress test. 
 
The Plan follows Medicare rules. Medicare rules say that cardiovascular nuclear imaging services are subject to 
the criteria listed 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 myocardial perfusion imaging services. 
Our reviewer says that the requested nuclear imaging services are not medically reasonable and necessary. Our 
physician reviewer found at issue is the medical appropriateness and necessity of carrying out a radionuclide 
stress test. The patient has a history of hypertension. There is no documentation that his electrocardiogram 
shows uninterpretable pattern. There is no evidence provided that would support the need for radionuclide 
stress testing. In summary, there is insufficient documentation to support the medical necessity for the 
requested cardiac stress testing in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve myocardial perfusion imaging services (78452).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the 20% coinsurance for an inpatient hospital stay from 
September 23, 2021, to September 30, 2021.       
 
You asked the Plan to waive the 20% coinsurance for an inpatient hospital stay from September 23, 2021, to 
September 30, 2021. You say that you should not have to pay this amount as your out-of-pocket maximum had 
been met. The Plan denied your request. The Plan says you pay a 20% coinsurance for each in-network  
Medicare-covered hospital stay. The Plan contract also says your combined maximum out-of-pocket amount is 
$3500. 
 
 
 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 inpatient hospital care.  
 
You have been asked to pay $1,554.73 coinsurance for an inpatient hospital stay. The record also shows that at 
the time this claim was processed, you had met $1865.27 of the combined maximum out-of-pocket amount of 
$3,500.  Inpatient hospital stays fall within the inpatient hospital care benefit category. This means that you 
have been asked to pay less than the full 20% coinsurance 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 20% coinsurance for an inpatient hospital stay from September 23, 2021, to 
September 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital surgery provided on 
January 28, 2022. 
 
You asked the Plan to waive the copayment for the outpatient hospital surgery. You say that you were told on 
the phone that there would be no copayment. The Plan denied your request. The Plan says the copayment 
amount 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 $175 
copayment for Medicare-covered surgery services provided in an outpatient hospital.  
 
 
 
 
 
 You have been asked to pay a $175 copayment for the outpatient hospital surgery. Outpatient hospital 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 the 
outpatient hospital surgery provided on January 28, 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient has a past medical history of total hip 
replacement because of a hip fracture in December 2021 and is living in an assisted living facility since 
discharge from skilled nursing. There is ongoing weakness. The enrollees medical problems are stable. There 
are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
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 for the enrollee.