Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on March 08, 2022, 
to March 11, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. 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 $335 
copayment per day, per admission for days 1-6 of inpatient hospital care. Includes inpatient acute, inpatient 
rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care 
starts the day you are formally admitted to the hospital with a doctors order. The day before you are 
discharged is your last inpatient day. There were 3 days. $335 x 3 = $1,005. Therefore, results in the total cost 
sharing amount of $1,005. 
 
 
 You have been asked to pay a $335 copayment per day for inpatient hospital stay. This item/service 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 inpatient 
hospital stay on March 08, 2022, to March 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for An inpatient rehab stay provided from 
April 2, 2022, to April 14, 2022. 
 
You asked the Plan to waive the copayment for an inpatient rehab stay. You say that you had no idea there was 
this kind of cost sharing for this stay. 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 $215 
each day, for days 1-7 for inpatient hospital care (PA) ($215 x 7 = $1505).  
 
You have been asked to pay a total of $1505 for an inpatient rehab stay. An inpatient rehab stay falls within the 
Inpatient Hospital Care (PA) 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 
rehab stay provided from April 2, 2022, to April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the primary care (PCP) office visit 
provided on June 27, 2022. 
 
You asked the Plan to waive the copayment for the primary care (PCP) office visit. You say that this was your 
annual wellness visit. 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 $10 
copayment for primary care provider visits. 
 
You have been asked to pay a $10 copayment for the primary care (PCP) office visit. This item/service falls 
within the primary care provider 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. The records show that during the wellness visit, specific medical conditions 
were also addressed, including acid reflux, hyperlipidemia, and migraines. These services go beyond the scope 
of the annual wellness visit and are subject to the applicable copayTherefore, we decided that the Plan does not 
have to waive the copayment for the primary care (PCP) office visit provided on June 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
March 16, 2022. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that the copayment is too 
high and should be waived 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 for Ambulance Services. 
 
You have been asked to pay a $350 copayment for ambulance transportation. 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 ambulance 
transportation provided on March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye examination provided on March 17, 
2022. 
 
You asked the Plan to waive the copayment for an eye examination. You say that this was vor your routine eye 
examination and you should not have a copayment 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 Vision Care. 
 
You have been asked to pay a $40 copayment for an eye examination. This item/service falls within the Vision 
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. 
Your contract with the Plan say you must pay a $40 copayment for each Medicare-covered eye exam to 
diagnose and treat diseases and conditions of the eye. Therefore, we decided that the Plan does not have to 
waive the copayment for an eye examination provided on March 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 25, 2021, billed with 
codes 81292 and 81301. 
 
You asked the Plan to pay for the genetic testing billed. 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. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 25, 2021, billed with codes 81292 and 81301.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from April 1, 2021, to 
April 13, 2021. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were unaware your stay at a 
skilled nursing facility would not be approved because you were told they were in-network. The Plan denied 
your request. The Plan says this cost share 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 $0 
copayment per day for days 1 to 20 and $184 copayment per day for days 21 to 100 for each SNF stay.  
 
You have been asked to pay $2,208 for 13 days of a 33-day SNF stay ($184 per day x 13 days = $2,208). This 
item/service falls within the each SNF stay 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 SNF stay provided from April 1, 2021, to April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pairing/cutting of benign hyperkeratotic lesion provided on 
March 17, 2022. 
 
You asked the Plan to pay for pairing/cutting of benign hyperkeratotic lesion. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of 
pairing/cutting of benign hyperkeratotic lesion have not been met. Therefore, we decided that the Plan does not 
have to pay for pairing/cutting of benign hyperkeratotic lesion provided on March 17, 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 IRF care for appropriate therapy 
and dialysis management to be back to baseline. The Plan denied your request. The Plan says based on 
Medicare guidelines, the requested IRF services do not meet the requirements for approval. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Euro Style Drive Nitro Duet. 
 
You asked the Plan to pre-approve a Euro Style Drive Nitro Duet. You say that a standard device will not meet 
your medical needs. The Plan denied your request. The Plan says the requested walker is an upgraded device 
that exceeds the enrollee's medical needs. 
 
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 a Euro Style Drive Nitro Duet. Our 
reviewer says that Euro Style Drive Nitro Duet is not considered medically reasonable and necessary in this 
case. Our physician reviewer found you are a 65-year-old female with a medical history of diabetes mellitus 
type II, peripheral neuropathy, lower extremity edema, and hypertension. A clinical progress note dated August 
1, 2022, indicated that you have difficulty walking and standing due to foot pain. The requested walker was 
requested to provide offloading of your feet and elevation. There is limited clinical information regarding your 
current mobility status. There is also limited clinical information provided regarding why the requested walker 
is required versus a standard rolling walker given your medical 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 a Euro Style Drive Nitro Duet have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Euro Style Drive Nitro Duet.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the current medical needs of the enrollee 
can only be received at an LTACH setting. The Plan denied your request. The Plan says the LTACH admission 
was not met, and the enrollee's medical needs are being met in the current acute setting. 
 
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 does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  
 
  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 the LTACH services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve epidural steroid injections (ESI) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the ESIs must be performed under CT or fluoroscopy image 
guidance with contrast unless the patient has a documented contrast allergy or pregnancy where ultrasound 
guidance without contrast may be considered. 
 
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 requested services are considered medically reasonable and necessary in this case. The enrollee has chronic 
low back with radicular symptoms. She has had physical therapy. She takes Gabapentin and Mobic for pain. 
On MRI she has spinal stenosis at L4-L5 along with ligamentum hypertrophy resulting in severe stenosis. 
There is no documentation suggesting that fluoroscopy will not be used. Our physician reviewer found that the 
enrollee's condition meets criteria for coverage of these 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve epidural steroid injections (ESI) 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: Favorable

 
We decided that the Plan has to pay for the genicular nerve block (64454) provided on January 27, 2022. 
 
You asked the Plan to pay for the injection. You say that this code is covered by Medicare when billed with 
diagnosis code, G89.18. The Plan denied your request. The Plan says that the injection is 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 pay for the injection. Our reviewer says that the 
requested injection was considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided documentation indicates that the enrollee is at higher risk from the Obstructive Sleep Apnea 
(OSA). The reviewer found that a post-operative nerve block was indicated. Therefore, the reviewer found that 
the injection was 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 pay for 
the genicular nerve block (64454) provided on January 27, 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: Testing
Decision: Partially Favorable

 
We decided that the Plan has to waive $0.50 of the coinsurance for a pulmonary function test. We decided 
that the Plan does not have to waive $61.92 of the coinsurance for a pulmonary function test.  
 You asked the Plan to waive the 20% coinsurance for a pulmonary function test provided on May 12, 2022.. 
You say that you believe the diagnostic tests should have been paid by the Plan because the other charges, 
minus the specialist visit, were covered. The Plan says that the coinsurance applied is correct. 
 
We decided that the Plan has to waive $0.50 of the coinsurance billed for a pulmonary function test.  
 
The rules say that a Plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, coinsurance, and deductibles). Your contract with the Plan clearly says that you must pay 
20% coinsurance for a pulmonary function test. However, the Plan charged $0.50 over the amount allowed per 
the contract. Therefore, we decided that the Plan has to waive $0.50 of the coinsurance billed for a pulmonary 
function test.  
 
We also decided that the Plan does not have to waive $61.92 of the coinsurance billed for a pulmonary 
function test. 
 
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% of 
the allowed amount for a pulmonary function test. Therefore, we decided that the Plan does not have to waive 
$61.92 of the coinsurance for a pulmonary function test ($309.60 allowed x 20% = $61.92). 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts (L3000) and orthopedic footwear (L3216). 
 
You asked the Plan to pre-approve foot orthotics. You say that you received a prosthetic leg in 2019 and there 
has been a change in your leg size. You are requesting a new one and you cannot accept the leg that the Plan is 
offering because it is cheaper and not the one you are used to. The Plan denied your request. The Plan says this 
item is not a covered benefit. Your flat foot condition can be adequately treated with over-the-counter foot 
orthoses. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts (L3000) and 
orthopedic footwear (L3216).