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

 
We decided that the Plan does not have to waive the cost share for the nuclear medicine studies, cardiovascular 
stress test and regadenoson injection provided on December 8, 2021. 
 
You asked the Plan to waive the cost share for the cardiovascular procedures and Part B drugs. You say that 
you have a stress test done every year, and your copay has always been $50 for this service. 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 diagnostic radiology services and a $75 copayment for each covered diagnostic procedure. Your 
contract with the Plan clearly says that you must pay a 20% coinsurance for Part B drugs. 
 
You have been asked to pay a $327.54 copayment for the cardiovascular procedures and Part B drugs. The 
cardiovascular procedures fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. The Part B drug falls in the Medicare Part B Prescription Drugs benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the cost share for the nuclear medicine studies, cardiovascular stress test and 
regadenoson injection provided on December 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from August 12, 
2021, to August 18, 2021 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you cannot afford this 
copayment, it will cause a hardship. 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 $290 
each day for days 1 to 5 for inpatient hospital care.  
 
You have been asked to pay a $1450 copayment for a 5-day inpatient stay ($290 x 5 days = 1,450). An 
inpatient 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 stay provided from August 12, 2021, to August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of sclerosant; multiple incompetent veins 
(other than telangiectasia), same leg (CPT code 36471). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because the enrollee's records do not show they 
have varicose veins intended to be treated that are large enough. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found coverage criteria have not met as the documentation does not satisfactorily demonstrate that the 
enrollee's symptoms are related to the varicosities. It is unclear if the providers recommendation for neurology 
consult has been completed. Additionally, the enrollee's veins do not meet coverage size criteria. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg 
(CPT code 36471).
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 you have Parkinson's and the fall has made your 
walking and mobility worse. The Plan denied your request. The Plan says per Medicare guidelines, your needs 
can be met at a lower level of care, such as skilled nursing facility for skilled nursing and therapy services. 
 
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 you were admitted to an acute hospital on September 3, 2022 after a fall sustaining 
left shoulder subluxation. You were noted to have a urinary tract infection. There are no complex nursing or 
rehabilitation needs. While you have a need for physical 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 shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that your legs can not stand in too long. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that that the hospital should include all expenses for 
this admission with the enrollee's last hospital admission. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 hospital services. Our 
reviewer says that inpatient hospital services are medically reasonable and necessary. The enrollee has chronic 
asthma and chronic obstructive pulmonary disease (COPD) who was previously admitted to the acute care 
hospital with asthma/COPD exacerbation and pneumonia requiring intensive care unit care, intubation, 
antibiotics and steroids. The enrollee was discharged home with stable breathing, clear lungs. She was offered 
home health but refused it. She was readmitted days later with another asthma exacerbation following 
unresponsiveness and requiring intubation and IV steroids again. Based on the provided documentation, the 
patient appeared to require the second admission due to being unresponsive and requiring intubation and 
monitoring. The readmission, however, did not appear to directly be a result of premature discharge as the 
patient was stable on discharge with plans for ongoing home care. Our physician reviewer found that the 
enrollee's condition meets criteria for coverage of inpatient hospital services.  
 
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 hospital services have been met. Therefore, we decided that the Plan 
has to pre-approve inpatient hospital services for the enrollee.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on May 2, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you are allowed one hearing exam 
per year. 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 $25 
copayment for an office visit with a specialist.  
 
You have been asked to pay a $25 copayment for an office visit with a specialist. 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 provided on May 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the claim reprocessed for payment. 
The Plan denied your request. The Plan says the rendering provider is an OON provider and there was no 
referral from an in-network provider or an approved authorization. Also, the service 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 an office visit provided on May 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the oxygen concentrator rental provided on 
March 2, 2022. 
 
You asked the Plan to waive the cost share for the oxygen concentrator rental. You say that you cancelled the 
rental of the oxygen concentrator on March 1, 2022. 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 20% 
coinsurance for DME.  
 
The Plan confirmed with the provider that services are billed one month behind therefore the claim is correct. 
You have been asked to pay a 20% coinsurance for the oxygen concentrator rental for a total of $20.65 
($103.26 allowed amount x 20% = $20.65). The oxygen concentrator rental 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 cost share 
for the oxygen concentrator rental provided on March 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B injection on May 04, 2022. 
 
You asked the Plan to waive the coinsurance for Part B injection. 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 20% 
coinsurance for Medicare Part B drugs. Medicare Part B drugs are subject to the 20% coinsurance. You will 
also pay cost-sharing for any associated professional services provided at a doctors office or outpatient 
facility, depending on the location of service (excluding chemotherapy drugs). The provider billed in the 
amount of $45,010 and the allowed amount is $9,878.43. $9,878.43 x 20% = $1,975.69. Therefore, results in 
the total cost sharing amount of $1,975.69. 
 
 
 
 
 You have been asked to pay a 20% coinsurance for Part B injection. Part B injections fall within the Medicare 
Part B prescription drugs 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 Part B 
injection on May 04, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for J. Martin, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain injections to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON pain injections. You say that the enrollee suffers from upper back 
and neck pain. The Plan denied your request. The Plan says medically necessary care is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
pain injections to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested 
transportation services are medically necessary, as you are seriously injured with broken bones. The Plan 
denied your request. The Plan says your benefit for routine transportation is exhausted for the year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way routine transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that the Plan has covered 24 one-way routine transportation trips for you in 2022. Based on this information, we decided that 
you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided 
that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode with 
Auto-EPAP (AE) that could be delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found Medicare does not cover a home ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal 
epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (CPT code 64483). 
 
You asked the Plan to pre-approve the injection. You say that the procedure is required for the enrollee to 
obtain maximum function, reduced pain and a better quality of life. The Plan denied your request. The Plan 
says that the Medicare rules have not been met. 
 
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 injection. Our physician reviewer 
found the enrollee has had low back pain for greater than 6 months. The request meets LCD criteria for an 
epidural steroid injection. The request is medically reasonable and 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 the injection have been met. Therefore, we decided that the Plan has to pre-
approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance 
(fluoroscopy or CT), lumbar or sacral, single level (CPT code 64483).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 7, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an adequate number of attempts have been made by the plan to request medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the labs have been met. Despite 
multiple attempts on the plan's part, the laboratory has not sent in any valid medical records for review. They have not made a valid attempt to show that criteria would be met for these services. Therefore, we decided that 
the Plan does not have to pay for laboratory services provided to the enrollee on January 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided November 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says medical records are missing to support the lab service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lab services provided November 
18, 2021. have been met. In this case the Plan requested medical records to support the services being billed 
and verify medical necessity. These records were not provided for review.  Therefore, we decided that the Plan 
does not have to pay for the lab services provided November 18, 2021.