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

 
We decided that the Plan does not have to pre-approve endoskeletal ankle foot system (Ossur Proprio foot) 
identified with code L5973 
 
You asked the Plan to pre-approve Ossur Proprio foot. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ankle/foot systems identified with code L5973 are for 
K3 ambulators. 
 
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 Ossur Proprio foot. Our reviewer says 
that the documentation does not support that the requested item is medically reasonable or necessary. Our 
physician reviewer found the enrollee's current prosthesis is no longer a fit and the enrollee has developed 
sores. The enrollee seems to fall because the leg is not fitting properly, and the ankle drags. There is little 
evidence the enrollee walks beyond K2 as it simply states the enrollee walks on uneven ground. A K2 
ambulator may walk on uneven ground. There is little evidence the enrollee has a variable cadence or has otehr 
activities beyond walking. Therefore, the enrollee does not meet criteria for the requested item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ossur Proprio foot have not been met. Therefore, we decided that the Plan does 
not have to pre-approve endoskeletal ankle foot system (Ossur Proprio foot) identified with code L5973
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A9279 billed for date of service June 9, 
2022. 
 
You asked the Plan to pay for procedure code A9279. You say that the claim should be paid. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A9279 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A9279 is not valid for Medicare purposes.  Based on this information, we decided that Medicare rules for coverage of procedure code A9279 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code A9279 billed for date of 
service June 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for office visits and a diagnostic 
laryngoscopy provided from June 30, 2022, to July 11, 2022, by out-of-network providers. 
 
You asked the Plan to waive the deductible and copayment for the out-of-network office visits and diagnostic 
laryngoscopy. You say that you would like to be reimbursed as much as possible. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1,000 deductible which applies to physician specialist services (out-of-
network) and outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers (out-of-network).  The item or service you asked the Plan to waive the deductible and copayment for falls within the physician 
specialist services (out-of-network) and outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers (out-of-network) benefit categories. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is $1,000 deductible which applies to physician specialist 
services (out-of-network) and outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers (out-of-network). This cost sharing is a contractual obligation that had not 
been met at the time the out-of-network office visits and diagnostic laryngoscopy was received on June 30, 
2022, to July 11, 2022.  
 
The file shows that the 40% coinsurance was applied to the out-of-network office visit and laryngoscopy 
provided on June 30, 2022. The out-of-network office visit provided on July 11, 2022, was processed as in-
network with a $50 copayment. Therefore, we decided that the Plan does not have to waive the deductible and 
copayment for office visits and a diagnostic laryngoscopy provided from June 30, 2022, to July 11, 2022, by 
out-of-network providers.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF is not medically 
necessary. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the documentation shows that the enrollee has active medical comorbidities and hospital complications 
thus the enrollee would be expected to require continued inpatient hospitalization during rehabilitation. Clinical 
documentation shows that the enrollee has complex functional impairments status post below-the-knee 
amputation (BKA) and would be expected to require interdisciplinary team management of rehabilitation in an 
IRF setting. Evaluating therapists state that the enrollee would be expected to tolerate an intense rehabilitation 
regimen and recommend IRF thus IRF criteria have been met. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 care provided on March 
29, 2022, to March 31, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are disputing your cost 
share. 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 $550 
copayment for inpatient hospital care. 
 
You have been asked to pay a $550 copayment for inpatient hospital care. 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 care provided on March 29, 2022, to March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compressor. You say that the services are better through another 
company. The Plan denied your request. The Plan says services must be obtained from an in-network provider. 
 
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 
a pneumatic compressor to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on August 
20, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you had no other means 
of transportation, and the doctor advised you to go to emergency. 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 $260 
copayment for ground or water ambulance services. 
 
You have been asked to pay a $260 copayment for the ambulance services. This item/service falls within the 
ground or water ambulance services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the ambulance services provided on August 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a sleep study. You say that why can't you go where you want? This office is 
the closest to your home. The Plan denied your request. The Plan says there is no pre-authorization on file for 
this service from your primary care provider (PCP). This is different than a referral. You can ask them for a 
pre-authorization or go to an in-network sleep facility. 
 
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 
a sleep study to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you state that a prior authorization should not be 
needed. The Plan denied your request. The Plan says a prior authorization is required for out of network 
providers. 
 
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 July 28, 2022, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound on June 20, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. 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 $75 
copayment for diagnostic procedures and tests, including ultrasounds. Covered services include but are not 
limited to other outpatient diagnostic tests including Advanced Imaging Services (e.g., Magnetic Resonance 
Imaging [MRI], Magnetic Resonance Angiography [MRA], Positron Emission Tomography [PET], Computed 
Tomography [CT] scans and Nuclear Medicine Testing). 
 
You have been asked to pay a $75 copayment for ultrasound. This item/service falls within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for ultrasound on June 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided on February 26, 
2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you had no control over which 
provider you saw. You should have already hit your deductible. 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 $200 
deductible for inpatient hospital care.  
 
You have been asked to pay $15.84 as part of the $200 deductible for an inpatient 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 
an inpatient stay provided on February 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 07, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that medical records were submitted to support 
medical necessity. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on June 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on August 22, 
2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you had already met your $4,500 
MOOP for the year. 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 $30 
copayment for services received from a level 1 specialist physician. 
 
You have been asked to pay a $30 copayment for the office visit. This item/service falls within the services 
received from a level 1 specialist physician 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 file shows that on the date of service, the maximum out-of-pocket 
(MOOP) expenses had not been met. Therefore, we decided that the Plan does not have to waive the 
copayment for the office visit provided on August 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve imaging to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve imaging. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 
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 
imaging to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Invitae Acute Hepatic Porphyrias Panel. 
 
You asked the Plan to pre-approve Invitae Acute Hepatic Porphyrias Panel. 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 follows Medicare rules. Medicare rules say that testing is covered under certain conditions. 
 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 Invitae Acute Hepatic Porphyrias Panel. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
reviewed documentation indicates that the requested genetic testing is not covered under Medicare guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Invitae Acute Hepatic Porphyrias Panel have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Invitae Acute Hepatic Porphyrias Panel.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on July 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there is no referral on file from the primary care provider. 
 
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 genetic testing provided on July 15, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Rheumatologist office visit to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve a Rheumatologist office visit. You say that you would like a referral for an 
out of Plan second opinion consultation. The Plan denied your request. The Plan says services requested are 
available with in-network providers. 
 
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 
a Rheumatologist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on December 9, 2021. 
 
You asked the Plan to waive the coinsurance for injections. You say that the provider's office told you this 
would be covered 100%. 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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this drug or item is $238.80, 
resulting in a coinsurance amount of $47.76 ($238.80 x 20% = $47.76). 
 
You have been asked to pay a $47.76 coinsurance for injections. This item/service falls 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 injections 
provided on December 9, 2021.