Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled care and aide services. 
 
You asked the Plan to pre-approve home health care. You say that the enrollee's caregiver has health issues. 
The Plan denied your request. The Plan says the denial of authorization for home health care is correct. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health care. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested home health care. Our physician reviewer 
found the enrollee does not have documented home health physical therapy needs. The enrollee's care needs 
appear to be custodial and long-term, rather than restorative or intermittent. As such, the requested home health 
physical therapy and aide services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health skilled care and aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CPAP supplies on November 17, 2021. 
 
You asked the Plan to waive the copayment for CPAP supplies. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the coinsurance applied 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 CPAP supplies. The total allowed amount of the CPAP supplies is $107.88, resulting in a 
coinsurance amount of $21.58. 
 
You have been asked to pay a 20% coinsurance for CPAP supplies. CPAP supplies falls within the Durable 
medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for CPAP supplies on November 17, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
February 7, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you would like to 
appeal the denied charges. The Plan denied your request. The Plan says the proper copayment was applied for 
the service that was rendered. 
 
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 $65 
copayment for each emergency room visit.  
 
  You have been asked to pay a $65 copayment for an emergency room visit. An emergency room visit falls 
within the Emergency 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 
emergency room visit provided on February 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug treatment provided on October 28, 2021. 
 
You asked the Plan to pay for the drug treatment. The Plan denied your request. The Plan says the requested 
service/procedure was not medically necessary and is not a standard of care for this enrollee. 
 
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 drug treatment provided on 
October 28, 2021. have been met. The Plan did not provide sufficient medical records for this case. Without 
this information we cannot determine that the Plan's coverage rules support the denial of payment in this case. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan does not have to pay for the drug treatment provided on October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you have had a fall and have spent over 
$1,100 in supplies. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the requested items are a necessity for 
your care. The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on February 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home visit. You say that you are resubmitting the claim with supporting 
documentation to support the home visit. The Plan denied your request. The Plan says no prior authorization 
was obtained. 
 
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 
home visit. We found no exception that would require the Plan to pay for the home visit. The records provided 
for review do not show that the home visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the home visit provided on February 3, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a user-adjustable heel height feature. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a user-adjustable heel height feature (L5990) will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The item at issue is a user-adjustable heel height feature. This item is 
not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a user-adjustable 
heel height feature.
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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 medically necessary. Our physician reviewer found you had a right total knee 
replacement and are at home receiving skilled therapy services. The records show that you are medically stable 
with no acute medical problems. You do not require supervision by a physical medicine and rehabilitation physician three or more times per week. You have no acute nursing needs. You do not require the intensive 
therapy program in an IRF. The IRF admission is not medically necessary based lack of medical complexity 
and acute rehab nursing 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for anesthesia services provided on February 
9, 2022. 
 
You asked the Plan to waive the coinsurance for anesthesia services. You say that you were not informed of 
any additional charges prior to surgery by the provider performing the surgery or the outpatient surgery center. 
You also say that you were told you would only pay a $250 copayment per eye. You also say that the Plan told 
you that the provider was out-of-network, but the providers say they are in-network. The Plan denied your 
request. The Plan says you were 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 30 
percent coinsurance for out-of-network surgery services.  
 
You have been asked to pay $17.70 in coinsurance, which is 30 percent of the allowed amount for anesthesia 
services ($59 allowed amount x 30% coinsurance = $17.70). Anesthesia services falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 anesthesia services provided on February 9, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on February 16, 2022. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says there is no 
current order from the member's primary care physician (PCP) or attending physician for the services. 
 
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 psychotherapy provided on  
February 16, 2022 have been met. Therefore, we decided that the Plan does not have to pay for psychotherapy 
provided on February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgery services provided on February 2, 
2022, and February 16, 2022. 
 
You asked the Plan to waive the copayment for surgery services. You say that the enrollee should not be billed 
for a copay when he was there for a total of 30 minutes. The Plan denied your request. The Plan says the 
copayment was applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay, when in-network, a $350 copayment per visit for outpatient surgery services.  
 
The enrollee has been asked to pay $700 ($350 copay x two visits) for surgery services. Surgery services fall 
within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based 
on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient 
surgery services provided on February 2, 2022, and February 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on January 3, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you would like this claim re-
processed for payment. The Plan denied your request. The Plan says the copayment was applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $275 copayment for each one-way Medicare-covered ambulance service.  
 
The enrollee has been asked to pay $275 for ambulance services. Ambulance services fall within the 
Ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance services provided on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility care visit provided on January 10, 2022. 
 
You asked the Plan to pay for a nursing facility care visit. You say that the doctor treated the enrollee at the 
facility and they did not have an authorization for them. The Plan denied your request. The Plan says the out-
of-network services were not authorized 
 
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 nursing facility care visit provided on January 
10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a urine flow pressure test, bladder imaging 
review, and an iodine contrast injection provided on October 29, 2021. We also decided that the Plan does not 
have to waive the copayments for a specialist office visit and ultrasounds of the bladder and pelvis provided on 
November 9, 2021. 
 
You asked the Plan to waive the copayments and coinsurance for the urine pressure test, imaging review, 
contrast injection, office visit, and ultrasounds. You say that you were informed by the provider that you would 
not have to pay more than $75. The Plan denied your request. The Plan says the correct copayments and 
coinsurance were applied.  
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 services provided in a specialist's office. 
 
Your contract with the Plan also clearly says that you must pay a $160 copayment for radiological diagnostic 
services and a 20% coinsurance for medical supplies, such as chemical agents used in certain diagnostic 
procedures. 
 
Service Copayment/Coinsurance per EOC Actual Charged Amount 
Urine Pressure Test $40.00 $40.00 
Bladder Imaging Review $160.00 $128.59 
Contrast Injection 20% of $21.00 $4.20 
Office Visit $40.00 $40.00 
Bladder Ultrasound $160.00 $12.88 
Pelvic Ultrasound $160.00 $160.00 
Total:  $385.67 
 
You have been asked to pay a total of $385.67 for the urine pressure test, imaging review, contrast injection, 
office visit, and ultrasounds. The urine pressure test and office visit fall within the Physician/Practitioner 
Services, Including Doctor's Office Visits benefit category. The imaging review, ultrasounds, and contrast 
injection fall 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 copayments for a urine flow pressure test, bladder imaging review, and an 
iodine contrast injection provided on October 29, 2021. We also decided that the Plan does not have to waive 
the copayments for a specialist office visit and ultrasounds of the bladder and pelvis provided on November 9, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the chest and x-ray services provided on January 
5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an x-ray of the chest and x-ray services. You say that you cannot always call to 
make sure you have prior authorization, because many times the services are done on the same day they are 
ordered. The Plan denied your request. The Plan says services from non-participating providers are not covered 
under open access 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 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 x-ray of the chest and x-ray services provided 
on January 5, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visits (99335) provided on November 3, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the rendering provider is 
credentialed with the provider group. You also say that this should be paid. The Plan denied your request. The 
Plan says the enrollees claim would be covered under Original Medicare as it is responsible for coverage of 
Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The 
Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and 
to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the rest home visits (99335) provided on November 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on 
November 9, 2021. 
 
You asked the Plan to waive the copayment for the hospital stay. You say that you received no help in anyway 
and want your money back. The Plan denied your request. The Plan says the copayment was applied 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 $430 
copayment per day for days 1-4.  
 
 
  You have been asked to pay $860 ($430 copay x 2 days) for the hospital stay. The hospital stay falls within the 
Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient 
hospital stay provided on November 9, 2021.