Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit on November 9, 
2021. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you should not have to pay 
this bill because you had an allergic reaction to the COVID-19 vaccine. The Plan denied your request. The Plan 
says copayment 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 $90 
copayment for emergency care. Cost-sharing is waived if you are admitted to the hospital within 24 hours.  
 
  You have been asked to pay $90 copayment for the emergency room visit. The 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 emergency 
room visit on November 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 
inpatient skilled nursing facility care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that 
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee 
does not require skilled nursing or skilled therapy services on a daily basis. Additionally, as a practical matter, 
the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve inpatient skilled nursing facility (SNF) care.
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 therapy would be a great thing for the enrollee to be 
able to return home. The Plan denied your request. The Plan says the denial of authorization for IRF care is 
correct. 
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee may need physical and/or occupational therapy, there is no documented need for an intensive 
rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in 
- and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for psychiatric evaluation provided on 
December 10, 2021, and family psychotherapy provided on December 17, 2021. 
 
You asked the Plan to waive the deductible for psychiatric evaluation and family psychotherapy. You say that 
this claim was for services covered under part B coverage. You say that your deductible for 2021 was met. The 
Plan denied your request. The Plan says The Plan says the deductible applied correctly. 
 
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 a $1484 medical deductible for most Part A services received from both 
in-network and out-of-network providers. You can find this information in Chapter 4, pages 4 and 5 of the 
Plan's 2021 Evidence of Coverage (EOC). 
 
 
 
 The item or service you asked the Plan to waive the deductible for falls within the Skilled nursing facility 
benefit category because you were inpatient at the time the services were received. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $1,484 deductible which applies to covered 
Medicare Part A services received from both in-network and out-of-network providers. This cost sharing is a 
contractual obligation that had not been met at the time psychiatric evaluation and family psychotherapy were 
received on December 10, 2021 and December 17, 2021. Therefore, we decided that the Plan does not have to 
waive the deductible for the psychiatric evaluation provided on December 10, 2021 and family psychotherapy 
provided on December 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from July 12, 2021, through July 
14, 2021, at DRG 872. 
 
You asked the Plan to pay for inpatient services at DRG 872. You say that the physician diagnosed the patient 
with sepsis with organ dysfunction and was managed appropriately. You say that the denial should be 
overturned and payment approved for the originally billed DRG 872. The Plan denied your request. The Plan 
says the documentation is incomplete to support a diagnosis of sepsis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services at DRG 872 with principal diagnosis code A41.9, defined as 
sepsis, unspecified organism and secondary diagnosis code R65.20, defined as severe sepsis without septic 
shock. 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 pay for inpatient services at DRG 872. Our 
reviewer says that the documentation does not support diagnosis codes A41.9 and R65.20. Our physician 
reviewer found that the physician diagnosed the enrollee with sepsis with organ dysfunction but there was no 
clinical or laboratory evidence of sepsis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from July 12, 2021, through July 14, 2021, at DRG 872.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Skilled Nursing Facility services provided on September 1, 
2021 to September 30, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Skilled Nursing Facility services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 Skilled Nursing Facility services provided on 
September 1, 2021 to September 30, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crutch substitute (E0118). 
 
You asked the Plan to pre-approve the crutch substitute. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must cover what Medicare covers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the knee scooter have not been met. Specifically, this item is not a covered benefit of Medicare or 
the Plan. Therefore, we decided that the Plan does not have to pre-approve the crutch substitute (E0118).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a denosumab injection provided on 
December 28, 2020, and June 30, 2021, and a specialist office visit provided on September 29, 2021. 
 
You asked the Plan to waive the cost share for the injections and a specialist office visit. You say that you have 
never had bills in the past for this doctor or for the services he provided. You also say the billing staff told you 
this was a "hick up" and the bill was overlooked. 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 20% 
coinsurance for in-network Part B drug. The Plan contract also says that enrollees must pay a $35 copayment 
for an in-network specialist office visit. 
 
The record shows these claims were approved, and you have a cost share amount for each service. You have 
been asked to pay $240.72, which is 20% coinsurance of the allowed amount for each injection received on 
December 28, 2020, and June 30, 2021 ($1,203.60 allowed amount x 20% coinsurance = $240.72). An 
injection falls within the Medicare Part B Prescription Drug benefit category.  
 
You have also been asked to pay a $35 copayment for a specialist office visit on September 29, 2021. A 
specialist office visit falls within the Physician/Practitioner Services, Including Doctors Office Visits benefit 
category. You have been asked to pay a total of $516.44 ($240.72 coinsurance + $240.72 coinsurance + $35 
copayment = $516.44). 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 cost share for a denosumab injection provided 
on December 28, 2020, and June 30, 2021, and a specialist office visit provided on September 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this procedure fills a treatment gap for patients that 
do not receive adequate relief from traditional conservative methods and do not have instability to indicate 
fusion is the appropriate treatment. The Plan denied your request. The Plan says the denial of authorization for 
this service is correct, because studies have not proven that this is helpful for treatment of the enrollee's health 
problem. 
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure is experimental, more research is needed to show its safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of inpatient 
skilled nursing facility care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that 
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that you do not 
require skilled nursing or skilled therapy services on a daily basis. Additionally, you do not meet severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee had a lumbar infusion and has 
Parkinsons disease, and it would be unsafe for the enrollee to go home and from a surgical standpoint. The 
Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
and/or skilled therapy services on a daily basis. The enrollee is medically stable and can receive further 
rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to 
improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care 
than a SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 will require 3-4 weeks of 
LTACH care to continue aggressive pulmonary toileting and to transition from his acute illness. The Plan 
denied your request. The Plan says the enrollee needs can be provided in another setting, such as an acute 
rehabilitation facility, skilled nursing facility, outpatient setting or home care. 
 
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 enrollees needs can 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a Prolia (denosumab) injection provided on 
June 18, 2021, and December 20,2021, and laboratory services (codes 82565 and 82310) provided on June 18, 
2021. 
 
You asked the Plan to waive the cost share for an injection and laboratory services. You say that when you 
started getting the Prolia injections in 2020 they were covered at 100%. You also say that you were told your 
doctor used the incorrect codes. 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 20% 
coinsurance for in-network Part B drugs. The Plan contract also says that enrollees must pay a $20 copayment 
for in-network lab services. 
 
The record shows these claims were approved, and you have a cost sharing amount for each service. You have 
been asked to pay $248.31, which is 20% coinsurance of the allowed amount for an injection on June 18, 2021 
($1,241.56 allowed amount x 20% coinsurance = $248.31). You have also been asked to pay $254.28, which is 
20% coinsurance of the allowed amount for an injection on December 20, 2021 ($1,271.40 allowed amount x 
20% coinsurance = $254.28). An injection falls within the Medicare Part B Prescription Drugs benefit 
category.  
 
You have been asked to pay $5.27, which is less than the $20 copayment for laboratory services (code 82565). 
You have also been asked to pay $5.31, which is less than the $20 copayment for laboratory services (code 
82310). Laboratory services 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 cost share for a Prolia (denosumab) injection 
provided on June 18, 2021, and December 20,2021, and laboratory services (codes 82565 and 82310) provided 
on June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a lumbar-sacral orthosis provided on 
October 30, 2021. 
 
You asked the Plan to waive the coinsurance for a lumbar-sacral orthosis. You say that this brace cost too much 
and it is already falling apart. You also say that you were told your insurance would pay for all of it and there 
would be no charge to you. 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 20% 
coinsurance for in-network Medicare-covered orthotics.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$163.12, which is 20% coinsurance of the allowed amount for a lumbar-sacral orthosis ($815.58 allowed 
amount x 20% coinsurance = $163.12). A lumbar-sacral orthosis 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 coinsurance for a lumbar-sacral 
orthosis provided on October 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro device (L8702). 
 
You asked the Plan to pre-approve the MyoPro device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is experimental. 
 
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 MyoPro device. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records provided do not include medical records from the ordering physician that establish 
the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
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 MyoPro device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the MyoPro device (L8702).