Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay the deductible and coinsurance for the durable medical 
equipment (DME) supplies provided on October 26, 2021. 
 
You asked the Plan to pay the deductible and coinsurance for the DME supplies. You say that you were told 
everything would be fully covered and all you would have to pay is the coinsurance. The Plan denied your 
request. The Plan says the appeal was partially overturned due to the enrollee being balanced billed and a 
reimbursement was approved. Afterwards the proper deductible and coinsurance was applied for the claim. 
 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 $150 
deductible is the amount you have to pay out-of-pocket before the plan will pay its share for your covered In-
network Medicare Part A and B services. Prior to October 26, 2021, the total amount paid towards the $150 
deductible was $110.27 leaving $39.73 ($150 total deductible - $110.27 paid towards deductible) to pay 
towards the deductible. The total amount allowed for the first DME supply was $49.89. Therefore the $39.73 
was charged as the deductible. 
 
Your contract with the Plan clearly says that you must pay a 4% coinsurance for the total cost for each 
Medicare-covered item. After the deductible was charged for the first item it left a total amount balance of 
$10.16 with a coinsurance of $0.41 ($10.16 total amount x 4% coinsurance). The next items total amount 
charged was $3.11 with a coinsurance of $0.12 ($3.11 total amount charged x 4% coinsurance). The next 
items total amount allowed was $80.01 with a coinsurance of $3.20 ($80.01 total amount allowed x 4% 
coinsurance). The next items total amount charged was $17.19 with a coinsurance of $0.69 ($17.19 total 
amount allowed x 4% coinsurance). The last items total amount charged was $15.03 with a coinsurance of 
$0.60 ($15.03 total amount allowed x 4% coinsurance). The total amount charged for coinsurance was $5.02 
($0.41 coinsurance + $0.12 coinsurance + $3.20 coinsurance + $0.69 coinsurance + $0.60 coinsurance) 
 
You have been asked to pay a $39.73 deductible and a $5.02 coinsurance for the DME supplies. The deductible 
falls within the Annual Deductible benefit category. The DME supplies 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 pay the deductible and 
coinsurance for the durable medical equipment (DME) supplies provided on October 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay on December 18, 
2021 to December 22, 2021. 
 
You asked the Plan to waive the copayment for An inpatient hospital stay. You say that you don't think it is fair 
that you are being accessed this amount of cost. The Plan denied your request. The Plan says the copayment 
applied was 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 $220 
copayment per day per admission for an inpatient hospital stay. The total cost share is $880. 
 
You have been asked to pay a $220 copayment per day per admission for an inpatient hospital stay. An 
inpatient hospital stay falls 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 an inpatient hospital stay on December 18, 2021 to December 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric admission. 
 
You asked the Plan to pre-approve inpatient psychiatric admission. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric admission. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, you do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of April 25, 2022, forward as you were not shown to be a danger to yourself or others. 
You were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment. 
You were not showing any aggressive behaviors, or any treatment required for acute threats of safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic services provided on 
December 23, 2021 and December 30, 2021. 
 
You asked the Plan to waive the copayment for chiropractic services. You say that you should be reimbursed 
for the copayment you paid. The Plan denied your request. The Plan says the 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 pay $20 
copayment for Medicare covered chiropractic services.  
 
 
  You have been asked to pay a total of $40, for the chiropractic services ($20/visit x 2 = $40). The chiropractic 
services fall within the Chiropractic 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 Chiropractic services provided on December 23, 2021 and December 30, 2021.
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 as LTACHs and acute care hospitals (ACHs) are licensed to provide the same level 
of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current 
ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower 
level of care for any ongoing long-term care needs. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit provided on 
December 1, 2021. 
 
You asked the Plan to reduce the copayment for the specialist office visit. You say that you were overcharged 
for a PCP visit. 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 $35 
copayment for each specialist office visit.  
 
The file shows that the Plan verified the provider is a specialty provider. Therefore, you have been asked to pay 
a $35 copayment for the specialist office visit. The specialist office visit falls within the Physician/Practitioner 
Services, Including Doctor's 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 reduce the copayment 
for a specialist office visit provided on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 8, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that due to the ongoing coronavirus (COVID-19) 
pandemic our authorization department is severely understaffed, and we are unable to catch each and every 
patient and see if they need authorization or not. The Plan denied your request. The Plan says this provider is 
not a network provider with the Plan, and 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 an office visit provided on November 8, 2021, by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 based on the medical records provided there is 
no documentation that you require the services on an inpatient basis, only in a skilled nursing facility setting. 
Records do not document that services in the home with home health care or in a long-term care facility on a 
part time basis are not appropriate in this case. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to restore blood flow to the lower extremities. 
 
You asked the Plan to pre-approve surgery to restore blood flow to the lower extremities. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 surgery to restore blood flow to the 
lower extremities. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the documentation does not support the medical 
necessity of the treatments in question. It is documented that part of the plan was to obtain ankle brachial index 
(ABIs) and aortoiliac duplex. Results of the studies have not been provided. This is particularly important as it 
is documented the enrollee is having symptoms bilaterally however the duplex provided does not demonstrate 
similar arterial findings on the right side. Additionally, this enrollee has multiple other potential etiologies for 
leg discomfort including diabetes, fibromyalgia, and advanced age. There are no signs of limb threat. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgery to restore blood flow to the lower extremities have not been met. Therefore, we decided that the Plan does not have to pre-approve surgery to restore blood flow to the lower 
extremities.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 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 skilled nursing facility. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Romosozumab. 
 
You asked the Plan to pre-approve Romosozumab. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Romosozumab. Our reviewer says that 
the medication is not medically necessary. Our physician reviewer found the Food and Drug Administration 
has not stated that the requested drug is indicated for your condition. The Medicare approved drug compendia 
do not contain a supportive citation for the use of the requested drug in your clinical situation. The elements of 
the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Romosozumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Romosozumab.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 IRF admission is not medically necessary based on medical stability and lack of 
medical complexity, and lack of rehabilitation nursing needs. Documentation does not support the necessity for admission to 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder arthroscopy. 
 
You asked the Plan to pre-approve shoulder arthroscopy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 shoulder arthroscopy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. Therefore, the request for 
arthroscopy, shoulder, surgical, and capsulorrhaphy is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of shoulder arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve shoulder arthroscopy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for hyperbaric oxygen chamber services 
provided from October 26, 2021, to December 10, 2021. 
 
You asked the Plan to waive the copayments for the hyperbaric oxygen chamber services. You say that the 
provider informed you that there would be no copayments for the services. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for each specialist visit.  
 
You have been asked to pay a $45 copayment for each of the 12 hyperbaric oxygen chamber service visits. The 
total for all visits by this provider is $540 ($45 copayment x 12 visits = $540). The hyperbaric oxygen chamber services fall within the Physician/Practitioner Services, Including Doctor's 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 copayments for hyperbaric oxygen chamber services provided from 
October 26, 2021, to December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from June 4, 2021, to June 14, 2021. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were advised that the insurance 
company would be covering the stay at 100%. You also say you were not made aware of any copayments until 
December 2021 when you received a bill from the facility. 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). The enrollees contract with the Plan clearly says that enrollees must pay a $0 copayment for days 1-20 of a skilled nursing facility stay. The contract also says the enrollee 
must pay a $184 copayment per day for days 21-100 per benefit period. The Plan contract says that a benefit 
period begins on the first day you go to a skilled nursing facility and the benefits period ends when you have 
not been an inpatient at any skilled nursing facility for 60 days in a row. 
 
The record shows this claim was approved, and there is a cost sharing amount. The enrollee is not being 
charged for the first 20 days he was in the SNF from March 27, 2021, to April 14, 2021, and from June 4, 2021, 
to June 5, 2021. The enrollee is being asked to pay a total of $1,472, which is a $184 copayment per day for the 
remaining eight days from June 6, 2021, to June 14, 2021 ($184 copayment x 8 days = $1,472). A SNF stay 
falls within the Skilled Nursing Facility (SNF) Care benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for a skilled nursing facility (SNF) stay provided from June 4, 2021, to June 14, 
2021.