Persius/hicric huggingface dataset:
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 you need IRF care. The Plan denied your request. 
The Plan says criteria for admission to the IRF setting have not been met. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) 
provided on May 13, 2022. 
 
You asked the Plan to waive the copayment for the magnetic resonance imaging (MRI). You say that you were 
told the MRI was done incorrectly and you will need another. You say that you should not have to pay for this 
one. The Plan denied your request. The Plan says this cost sharing was charged 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 
$194.53 copayment for diagnostic radiology services that are not ultrasounds. 
 
You have been asked to pay a $194.53 copayment for the magnetic resonance imaging (MRI). This 
item/service falls within the diagnostic radiology services that are not ultrasounds 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. The allowed amount for this MRI was 
$194.53. Since this is less than the $250 copayment listed in the EOC, you are only responsible for the lesser 
amount. Therefore, we decided that the Plan does not have to waive the copayment for the magnetic resonance 
imaging (MRI) provided on May 13, 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. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to be up and moving, not lying in 
bed. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found that you have chronic left-sided low back 
pain after falling off a ladder. You have had chiropractic therapy. The physical examination documents a 
positive Patrick's and Yeoman's test as well as compression pain. Three diagnostic tests are noted. The SI joint 
injection is therefore reasonable and medically 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve a sacroiliac (SI) joint injection.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation of portable x-ray equipment provided on 
April 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the transportation of portable x-ray equipment. You say that this member 
requires these services due to medical necessity. The Plan denied your request. The Plan says a non-contracted 
provider who performed services to the member without prior authorization. 
 
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 transportation of portable x-ray equipment 
provided on April 27, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for two ambulance rides provided on June 15, 
2021. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that your provider advised you to 
go to the ER via ambulance after a motor vehicle accident. The Plan denied your request. The Plan says this 
cost sharing was charged 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 $250 
copayment for ambulance services. You have been asked to pay a $222.32 copayment, rather than the full 
copayment amount of $250 for an ambulance ride. You had two rides x $222.32 = $444.64. 
 
You have been asked to pay a $444.64 copayment for an ambulance ride. This item/service falls within the 
ambulance 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 two ambulance rides 
provided on June 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for durable medical equipment (DME) on May 
03, 2022. 
 
You asked the Plan to waive the deductible for durable medical equipment (DME). You say that you want to 
appeal the amount being charged. The Plan denied your request. The Plan says this cost sharing was charged 
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 $1000 deductible which applies to Durable medical equipment 
(DME) and related supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Durable 
medical equipment (DME) and related supplies. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $1000 deductible which applies to Durable medical equipment (DME) and related 
supplies. This cost sharing is a contractual obligation that had not been met at the time durable medical 
equipment (DME) was received on May 3, 2022. Therefore, we decided that the Plan does not have to waive 
the deductible for durable medical equipment (DME) on May 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an immunotherapy injection provided on 
February 17, 2022. 
 
You asked the Plan to waive the copayment for an immunotherapy injection. You say that you were told there 
would be no copayment for this. The Plan denied your request. The Plan says this cost sharing was charged 
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 $9.83 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $9.83 copayment for an immunotherapy injection. This item/service falls within 
the physician/practitioner services, including doctors office visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Your contract with the Plan clearly says that you 
must pay a $30 copayment for in-network consultation, diagnosis, and treatment by a specialist. However, you 
have only been asked to pay $9.83, which is less than the $30 copayment amount. Therefore, we decided that 
the Plan does not have to waive the copayment for an immunotherapy injection provided on February 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for endoscopy on April 12, 2022. 
 
You asked the Plan to waive the copayment for endoscopy. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $350 
copayment per visit at a hospital outpatient facility. If you are having surgery in a hospital facility, you should 
check with your provider about whether you will be an inpatient or outpatient. Unless the provider writes an 
order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing amounts for 
outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an outpatient. 
 
You have been asked to pay a $350 copayment for endoscopy. This item/service 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 endoscopy on April 12, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on May 9, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on May 9, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic eye test provided on 
November 12, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic eye test. You say that when I went in for this test 
the office staff told me I did not have to pay a copayment. I do not understand why I am being harassed for this 
copay. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $50 copayment for a diagnostic eye test. This item/service 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 eye test provided on November 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on May 
14, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that these charges are a result 
of your doctor damaging your throat. 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 $295 
copayment per one-way trip for ambulance services.  
 
You have been asked to pay a $295 copayment for the ambulance services. The ambulance services fall within 
the Ambulance 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 
ambulance services provided on May 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient hospital visit for a wrapping 
provided on April 15, 2022. 
 
You asked the Plan to waive the coinsurance for outpatient hospital visit for a wrapping. You say that you 
thought you had canceled this visit. The Plan denied your request. The Plan says you were charged this cost 
sharing correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance for outpatient hospital services. The allowed amount of this visit is $140.27 resulting in a $14.03 
coinsurance ($140.27 x 10% = $14.03). 
 
You have been asked to pay a $14.03 coinsurance for outpatient hospital visit for a wrapping. An outpatient 
hospital visit for a wrapping falls 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 coinsurance for outpatient hospital visit for a wrapping provided on April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 17, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you should not have to pay this 
copayment while in a SNF. The Plan denied your request. The Plan says this cost sharing was charged 
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 $40 
copayment for physician/practitioner services including doctors office visits. 
 
You have been asked to pay a $40 copayment for a specialist visit. This item/service falls within the 
physician/practitioner services including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist visit provided on March 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of 
the brain provided on May 3, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that Medicare should cover 80% or your 
costs and the Plan should cover the remaining 20%. 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 $200 
copayment for radiological services (not including X-rays).  
 
You have been asked to pay a $200 copayment for the MRI. This item/service 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 the magnetic resonance imaging (MRI) of the brain provided on May 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for endoscopy on April 20, 2022. 
 
You asked the Plan to waive the copayment for endoscopy. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for surgical services at ambulatory surgical center. If you are having surgery in a hospital facility, 
you should check with your provider about whether you will be an inpatient or outpatient. Unless the provider 
writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing 
amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an 
outpatient. 
 
 
 
 
 You have been asked to pay a $275 copayment for endoscopy. Endoscopy 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 endoscopy on April 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
March 14, 2022, to April 12, 2022. 
 
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that all HHAs must submit a NOA at the beginning 
of the initial 30-day period of care. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
documentation submitted does not include any evidence to support that a NOA was submitted at the beginning 
of the initial 30-day period of care. Therefore, we decided that the Plan does not have to pay for the home 
health services provided to the enrollee from March 14, 2022, to April 12, 2022.