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

 
We decided that the Plan does not have to waive the copayment for the office visit on July 28, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that there was no service provided. 
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 a $20 
copayment for each Medicare-covered visit with a specialist, regardless of services rendered.  
 
 
 
 
 You have been asked to pay a $20 copayment for the office visit. The office visit 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 the office visit on July 28, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the ER visit provided on July 7, 2021. 
 
You asked the Plan to pay for the ER visit. You say that this was an ER visit while you were on vacation. You 
say that you were told you don't owe this bill, but the bill has not been paid. The Plan denied your request. The 
Plan says that the provider failed to bill the appropriate modifier and a corrected claim has not been received. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan says the provider failed to bill the appropriate modifier. The Plan did 
not forward any claim information to support their denial that the appropriate modifier was not billed. It is the 
burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the ER visit 
provided on July 7, 2021.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
March 6, 2021, to March 17, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should not 
have a copayment due to your COVID-19 diagnosis. 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 $295 per 
day for days 1-6 and $0 per day for days 7-90 for each inpatient admission.  
 
The file shows that you were in the hospital from March 6, 2021, to March 17, 2021. The file also shows that 
cost share waivers for COVID-19 ended on February 15, 2021. Therefore, you have been asked to pay $295 per day for the first 6 days of inpatient hospital services. The total for your stay is $1,770 ($295 copayment x 6 
days = $1,770). The inpatient hospital services fall within the Inpatient Hospital Care benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for inpatient hospital services provided from March 6, 2021, to 
March 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that she needs intense physical therapy and occupational 
therapy to improve her strength, endurance, stamina, bed mobility, transfers, ambulation pattern and ability to 
perform activities of daily living as safe and independent as possible. You say that the patient meets the 
medical management criteria, and the appeal should be approved. The Plan denied your request. The Plan says 
services can safely be received in other settings. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve home ventilator. You say that you need volume assure pressure support 
which is not achieved with bi-level positive airway pressure (BiPAP). The Plan denied your request. The Plan 
says the denial of authorization for this device is correct, because a ventilator is not covered by Medicare for 
this purpose and a bi-level positive airway pressure (BiPAP) device with average volume assured pressure 
support (AVAPS) mode would meet all of your needs. 
 
The Plan must follow Medicare rules. Medicare rules say that a ventilator is not covered by Medicare when 
used to provide positive airway pressure therapy, regardless of the illness being treated.  
 
We looked at the file and Medicare rules. The requested ventilator is not covered for this purpose. The Plan 
says that a bi-level positive airway pressure (BiPAP) device with average volume assured pressure support 
(AVAPS) mode would meet your needs instead. Please contact the Plan regarding coverage of your treatment 
options. Based on this information, we decided that Medicare rules for coverage of home ventilator have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Computer Tomography (CT) scan on 
May 10, 2021. 
 
You asked the Plan to waive the copayment for a Computer Tomography (CT) scan. You say that you do not 
have money for this. The Plan denied your request. The Plan says the copayment of $148.45 you are being 
charged is correct since the amount due is under the normal $150 copayment. 
 
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 $150 
copayment for an in-network Computer Tomography (CT).  
 
 You have been asked to pay $150 copayment for a Computer Tomography (CT) scan. A Computer 
Tomography (CT) scan 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 Computer Tomography (CT) scan on May 10, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99215) provided on July 8, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the servicing provider is not a network provider with the Plan, and the claim 
was denied due to non-participating provider was billing for unauthorized services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99215) provided on July 8, 2021, 
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance services provided on November 
30, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 the ambulance services. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found the documentation did 
not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type 
of vehicle) were contraindicated for this patient. The documentation did not support that the patient needed the 
expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can 
provide for safe transport on 11/30/202. The documentation did not support that the ambulance transport was 
medically reasonable and necessary for the patient. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance services provided on 
November 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services rendered by the out-of-network (OON) 
provider on September 29, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the medical services rendered by the out-of-network (OON) provider on 
September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (36415, 80053, 80061, 82306) provided 
on October 18, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for laboratory services. You say that the services at issue were a necessity for the 
enrollee's care. The Plan denied your request. The Plan says rules for payment for out-of-network care have not 
been met. 
 
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 laboratory services (36415, 80053, 80061, 82306) 
provided on October 18, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a skilled nursing facility is not an 
appropriate level of care due to the time and complexity of the enrollee's care needs and the frequency of 
complications. You say that the enrollee meets the LTACH admission criteria, and it is your strong 
recommendation that LTACH level of care be approved. The Plan denied your request. The Plan says the 
enrollee is receiving the necessary care at the current hospital. 
 
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 enrollee requires additional short-term acute care services that can be safely 
administered at the current facility. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Completion of care at the current facility is recommended prior to transfer to a 
lower level of 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 meets the full criteria for an inpatient 
rehabilitation stay. The Plan denied your request. The Plan says authorization denied because the IRF 
admission is not medically necessary, and the enrollee's needs can be met at a lower level of care such as a 
skilled nursing facility (SNF). 
 
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 enrollee was admitted for pelvic fractures and a clavicle fracture after a fall. The 
record shows medical problems are stable, and there are no complex nursing or rehabilitation needs. The 
enrollee has a need for physical and/or occupational therapy, but 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
from June 3, 2021, to June 4, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should not be 
billed for these services. 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 a $200 
copayment per day for Medicare-covered hospital stays. This copay does not apply to the day you are 
discharged, so you are only being charged for June 3, 2021.  
 
 You have been asked to pay a $200 copayment per day for the inpatient hospital services. The inpatient 
hospital services fall within the Inpatient hospital care benefit category. This includes an intensive care unit. 
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 inpatient hospital services provided from June 3, 2021, 
to June 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
November 3, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you should not be 
responsible for the facility copayment because you already paid a $40 copayment to the physician. 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 $250 
copayment for in-network outpatient surgery. The Plan contract also says that additional copayment may apply 
depending upon the outpatient service received. 
 The record shows you may have additional copayments depending upon the outpatient service, including a 
diagnostic colonoscopy. You have been asked to pay a $250 copayment for a diagnostic colonoscopy. A 
diagnostic colonoscopy 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 colonoscopy provided on November 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on November 1, 
2021. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you were not told you would owe 
anything. You also say that if you had known the procedure would have a $350 copay, you would not have had 
it done. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for in-network outpatient surgery.  
 
Medical records show that polyps were removed during your colonoscopy. Therefore, the colonoscopy is 
considered diagnostic, and the outpatient surgery copayment applies. You have been asked to pay a $350 
copayment for a colonoscopy. A colonoscopy 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 colonoscopy provided on November 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on July 31, 2019. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you cannot afford the copayment. 
You also say that you were told this was a routine procedure and the doctor changed it to diagnostic without 
telling 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 a $350 
copayment for in-network outpatient surgery.  
 
The medical records show you had a diagnostic colonoscopy on July 31, 2019.  A diagnostic colonoscopy with 
biopsy is considered a surgical procedure. You have been asked to pay a $350 copayment for a colonoscopy. A colonoscopy 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 
colonoscopy provided on July 31, 2019.