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

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that please review for possible rehab 
admission. The Plan denied your request. The Plan says medical necessity cannot be established for SNF level 
of coverage 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled 
nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a 
daily basis and 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ophthalmic diagnostic imaging provided 
on December 7, 2021. 
 
You asked the Plan to waive the coinsurance for ophthalmic diagnostic imaging. The Plan denied your request. 
The Plan says the claim processed with the correct coinsurance. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies, diagnostic procedures and 
tests.  
 You have been asked to pay a 20% coinsurance for ophthalmic diagnostic imaging. The ophthalmic diagnostic 
imaging falls within the outpatient diagnostic tests and therapeutic services and supplies, diagnostic procedures 
and tests 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 ophthalmic diagnostic 
imaging provided on December 7, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an out-of-network hospital discharge provided on October 
29, 2021. 
 
You asked the Plan to pay for the hospital discharge. You say that the facility is an in-network provider, and 
this claim should be covered. The Plan denied your request. The Plan says the provider is an out-of-network 
provider, and the yearly deductible was not met. 
 
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 $1,000 deductible which applies to is the amount you have to pay out-
of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible 
amount, you must pay the full cost for most of your covered services. Prior to the date of service, the total 
amount paid towards the $1,000 was $253.33. Therefore, the total amount of $66.81 was charged towards the 
deductible. 
 
  The item or service you asked the Plan to pay for falls within the What is your plan deductible benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible. This 
cost sharing is a contractual obligation that had not been met at the time of the hospital discharge was received 
on October 29, 2021. Therefore, we decided that the Plan does not have to pay for an out-of-network hospital 
discharge provided on October 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor 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 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 
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
November 23, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that this service was a 
preventive service which should be fully covered. The Plan denied your request. The Plan says the 
documentation reviewed confirmed that the service provided was not a preventive service and was a diagnostic 
service. Therefore, the proper copayment 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 $35 
copayment for each basic imaging service.  
 
  You have been asked to pay a $35 copayment for the diagnostic mammogram. The diagnostic mammogram 
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 a diagnostic mammogram provided on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adjustable height receivers (K0108), an adapter plate 
(K0108), switch (K0108) and attendant controller (E2331) for a power wheelchair. 
 
You asked the Plan to pre-approve the adjustable height receivers, adapter plate, switch and attendant control.. 
You say that the requested accessories are medically necessary. The Plan denied your request. The Plan says 
coverage rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that code K0108 must not be used for any component 
or feature of an expandable controller at the time of initial issue. Rules also state that an attendant control 
cannot be covered in addition to a beneficiary-operated joystick. There is no separate payment for mounting 
hardware for a seat or back cushion. The correct code for an arm rest is E0973.  
 
We looked at the file and Medicare rules. The requested adjustable height receivers are miscoded. The correct 
code for this item is E0973, not K0108. An adapter plate is not separately payable from the provided seat or 
back cushion. Payment for the switch is included in the approved expandable controller, and the record shows 
this wheelchair includes an enrollee-operated joystick. An attendant controller cannot be covered in addition to this. Based on this information, we decided that Medicare rules for coverage of the adjustable height receivers, 
adapter plate, switch and attendant control. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve adjustable height receivers (K0108), an adapter plate (K0108), switch (K0108) and 
attendant controller (E2331) for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paring or cutting procedures on the skin (11055), and routine 
foot care (G0127, 11720) provided on August 25, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for paring or cutting procedures on the skin, and routine foot care. You say that at 
the time of service, the patient informed you that he/she is covered under Medicare, and it was impossible to 
obtain authorization, due to the patient misleading you with the incorrect insurance information. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also 
determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 paring or cutting procedures on the skin (11055), 
and routine foot care (G0127, 11720) provided on August 25, 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 for an Injection procedure for sacroiliac joint 
on October 25, 2021 
 
You asked the Plan to waive the copayment for an Injection procedure. You say that you are requesting that 
there isn't a copayment. The Plan denied your request. The Plan says the copayment 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 $295 
copayment for an Injection procedure for sacroiliac joint.  
 
You have been asked to pay a $295 copayment for an Injection procedure. An Injection procedure falls within 
the Injection procedure for 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 
an Injection procedure for sacroiliac joint on October 25, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiogram provided on June 8, 
2021. 
 
You asked the Plan to waive the copayment for the echocardiogram. You say that the service provided was 
billed wrong and not done in an outpatient hospital. The Plan denied your request. The Plan says it was 
determined that the services was rendered by a hospital and the claim was processed correctly. Therefore, the 
proper copayment 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 $100 
copayment for Basic Radiological Services in an Outpatient Hospital.  
 
  You have been asked to pay a $100 copayment for the echocardiogram. The echocardiogram 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 echocardiogram provided on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a CPAP machine and replacement parts 
from November 23, 2021 to December 27, 2021. 
 
You asked the Plan to waive the coinsurance for a CPAP machine and replacement parts. You say that you 
were advised by the plan that the provider is an in-network provider. The Plan denied your request. The Plan 
says the 16% 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 16% 
coinsurance for CPAP machine and replacement parts. The allowed amount of the Durable Medical Equipment 
(DME) is $213.28, resulting in a coinsurance amount of $41.19. 
 
 You have been asked to pay 16% coinsurance for a CPAP machine and replacement parts. A CPAP machine 
and replacement parts 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 a CPAP machine and replacement parts from November 
23, 2021 to December 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic testing (code 78452) 
provided on October 28, 2021. 
 
You asked the Plan to waive the copayment for outpatient diagnostic testing. You say that you would have 
refused the service if you had known the cost. 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 $200 
copayment for each type of Medicare-covered diagnostic radiology service including MRI, CT scans, Nuclear 
scans and PET scans, per date of service.  
 
 
 
 You have been asked to pay a $200 copayment for outpatient diagnostic testing. Outpatient diagnostic testing 
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 outpatient diagnostic testing (code 78452) provided on 
October 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic procedure provided on 
December 7, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic procedure. You say that this was just a screening 
process, and you would like the copayment waived. The Plan denied your request. The Plan says the 
documentation was reviewed, and the original screening process became a diagnostic procedure. Therefore, the 
copayment for outpatient surgery was properly 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 $325 
copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital 
facility.  
 
  You have been asked to pay a $325 copayment for the diagnostic procedure. The diagnostic procedure 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 a diagnostic procedure 
provided on December 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility (SNF) stay provided from August 4, 
2021, to August 24, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the SNF stay. You say that you were unaware that the enrollee switched 
insurance when the service was being rendered. You would like for the services to be paid because it was 
medically necessary to treat the enrollee. The Plan denied your request. The Plan says the rendering and 
referring providers are both out-of-network providers and there was no approved authorization. Also, the 
services 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 a skilled nursing facility (SNF) stay provided from 
August 4, 2021, to August 24, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapeutic services (97110, 97530) 
provided on October 26, 2021. 
 
You asked the Plan to waive the copayment for therapeutic services. You say that you did not know it was $35 
each time you went, and you thought your copayment was supposed to be $10. The Plan denied your request. 
The Plan says you were 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 $35 
copayment for Medicare-covered therapy visit.  
 
You have been asked to pay a $35 copayment for therapeutic services. Therapeutic services fall within the 
Medicare-covered therapy visit 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 
therapeutic services (97110, 97530) provided on October 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for an ultrasound provided on November 1, 
2021. 
 
You asked the Plan to lower the copayment for the ultrasound. You say that if you had seen an ot-of-network 
provider the copayment would have been cheaper. The Plan denied your request. The Plan says they cannot 
confirm if an out-of-network provider would have billed the same amount or would have billed higher than the 
in-network provider for this procedure. Therefore, the proper copayment 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 $160 
copayment for Medicare-covered radiological diagnostic services. The total amount allowed for this procedure 
was $120.26 which is less than the copayment amount of $160. Therefore, only $120.26 was charged as the 
copayment. 
 
  You have been asked to pay a $120.26 copayment for the ultrasound. The ultrasound 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 lower 
the copayment for an ultrasound provided on November 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on November 
10, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you should not have two 
copayments for tests on the same day. 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 $40 
copayment for basic radiological services at a free-standing radiological facility.  
 
The file shows that the Plan reprocessed the claim and removed one of the copayments. Therefore, you have been asked to pay one $40 copayment for the ultrasound. The ultrasound 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 a breast ultrasound provided on November 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy visit provided on 
November 2, 2021. 
 
You asked the Plan to waive the copayment for the physical therapy visit. You say that you cannot afford these 
charges. 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 $35 
copayment for Medicare-covered therapy visits.  
 
 
 
 You have been asked to pay a $35 copayment for the physical therapy visit. Physical therapy visits 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 copayment for 
the physical therapy visit provided on November 2, 2021.