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

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from June 17, 
2022, to June 24, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that this is too high of a copayment, 
and you are on a fixed income. 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 $395 
per day for days 1 to 5 for inpatient hospital care ($395 x 5 days = $1,975).  
 
You have been asked to pay a $1,975 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 from 
June 17, 2022, to June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wound care visit provided on June 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a wound care visit. You say that this should be covered and was a needed 
service. The Plan denied your request. The Plan says there was no preauthorization by a primary care provider 
(this is different than a referral) for an OON provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 a wound care visit provided on June 9, 2022, 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 outpatient diagnostic test and supplies 
provided on May 10, 2022. 
 
You asked the Plan to waive the coinsurance for outpatient diagnostic test and supplies. You say that the 
injection should have been included in the charge of the MRI. 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 20% 
coinsurance for Medicare-covered medical supply. The allowed amount of the injection total $18, resulting in a 
total coinsurance amount of $3.60. 
 
You have been asked to pay 20% coinsurance for outpatient diagnostic test and supplies. This item/service falls 
within the Medicare-covered medical supply 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 outpatient diagnostic test and supplies provided on May 10, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis (J2778). 
 
You asked the Plan to pre-approve Lucentis. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Lucentis. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Lucentis. Our physician reviewer found the Plan requires a 
trial of the ophthalmic formulation of Bevacizumab before they will approve the requested drug. In this case, 
the enrollee has not tried and failed the required drug(s). Our reviewer also found that there is no 
documentation provided indicating that the Plans required drug(s) would likely be less effective and/or likely 
have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis (J2778).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 4, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 4, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain 
(70450-26) provided on June 12, 2022. 
 
You asked the Plan to pay for a CT scan of the head or brain. You say that the claim was billed correctly. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 15, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for a CT scan of the head or brain have not been met. 
Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or 
brain (70450-26) provided on June 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new patient and follow-up office visits. 
 
You asked the Plan to pre-approve the new patient and follow-up office visits. The Plan denied your request. 
The Plan says we have providers who use radiation to destroy cancer cells or shrink tumors (Radiation 
Oncologists) available in-network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 provide the new patient and follow-up office visits. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found there is nothing 
unique about your condition that would make it medically necessary to continue care with the current 
physician. 
 
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 new patient and follow-up office visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a new patient and follow-up office visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for vision care and inpatient hospital care 
provided from April 22, 2022, to July 1, 2022. 
 
You asked the Plan to waive the coinsurance for vision care and inpatient hospital care. You say that you are 
appealing the denial of multiple claims with an out of network provider. 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 40% 
coinsurance for Medicare-covered hospital stay until discharge and vision care - Medicare covered visit. The 
allowed amounts of these Medicare-covered hospital stay and vision care  Medicare covered visit total 
$3,990.80, resulting in a total coinsurance amount of $798.16. 
 
You have been asked to pay 40% coinsurance for vision care and inpatient hospital care. This item/service falls 
within the Medicare-covered hospital stay until discharge and vision care - Medicare covered visit 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 vision care and inpatient hospital care 
provided from April 22, 2022, to July 1, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were informed this was no longer covered, and 
you would like to be reimbursed. The Plan denied your request. The Plan says a referral/authorization was not 
obtained prior to services being rendered. 
 
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 5, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an podiatry services provided on June 22, 
2022. 
 
You asked the Plan to waive the copayment for an podiatry visit. You say that you did not know each visit 
included a separate 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 podiatry services.  
 
You have been asked to pay a $40 copayment for podiatry visit. This item/service falls within the podiatry 
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 an podiatry services 
provided on June 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 20, 
2021, to December 21, 2021. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says the 
provided information does not support that criteria were met for an inpatient hospitalization. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the records document that the enrollee was traveling and missed dialysis. 
The enrollee was admitted for hemodialysis. Our reviewer found that there were no complications, and the 
enrollee was discharged on December 21, 2021. Our reviewer also found that the record does not show that at 
the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary 
hospital care (including earlier emergency department and/or observation care) would span two midnights. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from December 20, 2021, to 
December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 2, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says services from non-
participating providers are not covered unless preauthorized. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on June 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transport provided on 
September 20, 2021. 
 
You asked the Plan to waive the copayment for an ambulance transport. You say that you say that you were not 
sick and did not need an ambulance. 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 $300 
copayment for ambulance services.  
 
You have been asked to pay a $300 copayment for ambulance transport. 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 an ambulance 
transport provided on September 20, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation shows that the enrollee has functional impairments but does not 
show any IRF compliant diagnosis or complex functional impairments warranting interdisciplinary team 
management or intense therapy. Clinical documentation shows that the enrollee is medically stable and there 
are no active medical comorbidities thus not requiring inpatient hospitalization during rehabilitation. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine (72158). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. The Plan denied your request. The Plan says no 
information shows plain x-rays that showed no obvious abnormality of the axial spine, and there is no 
documentation of a trial or failure of conservative therapy. The Plan also says without a detailed neurological 
examination or documentation of conservative therapy, this request cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the lumbar spine. Our 
reviewer says that medical necessity of the requested MRI of the lumbar spine has not been established in the 
records provided. Our physician reviewer found the most recent clinical encounter was July 1, 2022, and at that 
time no neurological exam was conducted. The last x-ray of lumbar spine was on March 9, 2021, which 
showed no fracture, malalignment. Our reviewer found that there was no description of bowel or bladder lack 
of control or saddle paresthesia. No red flags to mandate immediate MRI without a 6-week trial of physical 
therapy. Our physician reviewer also found that the enrollee is taking opioids but has not had percutaneous 
injections, etc. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72158).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided from March 12, 2022, to March 
15, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that the managing physician(s) are of the opinion that 
the services provided were medically appropriate and necessary at the level of care provided. The Plan denied 
your request. The Plan says the enrollee does not meet inpatient criteria. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 inpatient care. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented to the hospital on March 11, 2022, with weakness and generalized body 
pain (chronic since 1991). Workup and vitals were unremarkable except for blood pressure was 145/75, 
137/78, and 150/78 although the enrollee had a history of hypertension. Our reviewer found that the next day 
the enrollee reported right knee pain, blood pressures were 129-157/80-103. The enrollee was able to ambulate 
with a steady gait, was alert and oriented, and workup was unremarkable. The enrollee was not in distress. Our 
physician reviewer found that based on this presentation described in the provided documentation, the enrollee 
was not expected to require hospital services that would likely cross 2 midnights due to the low severity and 
low complexity of the case. Our reviewer also found that the enrollee was stable near baseline. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient care provided from March 12, 2022, to March 15, 2022.