Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each debridement procedure provided on 
February 07, 2023, to February 28, 2023. 
 
You asked the Plan to reduce the copayment for each debridement procedure. You say that you though that you 
would only be charged $49.98. 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 $50 
copayment for outpatient hospital services. 
 
You have been asked to pay a $50 copayment for each debridement procedure. This item/service falls within 
the outpatient hospital 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. the total amount you owe is $200 ($50 copayment x 4 visits = $200). Therefore, 
we decided that the Plan does not have to reduce the copayment for each debridement procedure provided on 
February 07, 2023, to February 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital admission and care provided on February 1, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the hospital care. You say that you went into the hospital. You say that you were 
not in control of submitting a prior authorization. You also say that you feel this should be covered. The Plan 
denied your request. The Plan says the services in this case do not meet the inpatient criteria. 
 
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 in this case is not a network provider with the Plan. 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 the hospital admission and care provided on February 1, 2023, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation, and psychotherapy 
services provided on August 09, 2022, to October 04, 2022. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation, and psychotherapy services. You say that 
you were told that the provider was in-network. 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 a psychiatric diagnostic 
evaluation, and psychotherapy services provided on August 09, 2022, to October 04, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care and chronic care management services 
provided on December 12, 2022. 
 
You asked the Plan to pay for nursing facility care and chronic care management services. You say that you are 
appealing the claim payment denial. 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 nursing facility care and 
chronic care management services provided on December 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
December 07, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you do not owe a 
copayment because you initially drove yourself to the hospital. 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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for the 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 the 
ambulance transportation provided on December 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110 x 4) provided from  
January 20, 2023, through February 1, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the therapeutic exercises (97110 x 4) provided from January 20, 2023, 
through February 1, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Hyaluronan injection provided on 
December 28, 2021. 
 
You asked the Plan to waive the coinsurance for Hyaluronan injection. You say that you were not aware their 
was a cost share amount for the inejection. 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 Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Hyaluronan injection. 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 
Hyaluronan injection provided on December 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 13, 2023. 
 
You asked the Plan to pay for lab services. You say that the enrollee wishes to continue seeking services with 
this provider. 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 lab services provided on 
January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy procedure provided on July 
12, 2022. 
 
You asked the Plan to waive the copayment for the endoscopy procedure. You say that you should not have to 
pay for the procedure. 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 $100 
copayment for in-network outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $100 copayment for the endoscopy procedure. This item/service falls within the 
in-network outpatient surgery, including services provided at 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 copayment for the endoscopy procedure provided on July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator (E0747). 
 You asked the Plan to pre-approve an osteogenesis stimulator. You say that you have been in pain since your 
surgery 6 months ago. You also say that you have an implant, but the bone is not growing around the implant 
as it needs to, which is the reason why a bone growth stimulator was referred. The Plan denied your request. 
The Plan says you do not meet the coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that non-spinal electrical osteogenesis stimulator (E0747) 
is covered only if there i failed fusion of a joint other than in the spine where a minimum of nine months has 
elapsed since the last surgery. 
 
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 osteogenesis stimulator. Our 
reviewer says that you do not meet the coverage criteria for an osteogenesis stimulator. Our physician reviewer 
found not enough time has passed since the surgery. Our reviewer also found that only 6 months have passed. 
 
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 osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator (E0747).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left heart catheterization (93458). 
 
You asked the Plan to pre-approve left heart catheterization. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 left heart catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee had a recent negative radionuclide stress test. The left ventricular 
ejection fraction is normal. Documentation does not reveal the rationale for this invasive imaging study. 
Guidelines do not support a need for cardiac catheterization in this setting. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left heart catheterization (93458).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can benefit from acute rehabilitation to 
optimize their level of functioning prior to returning home. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and the enrollee's needs can be met at an alternate level of care.  
 
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 enrollee does not have any active medical comorbidities The enrollees needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the psychotherapy services provided by an 
out-of-network provider from January 17, 2023, to January 31, 2023. 
 
You asked the Plan to waive the deductible for the psychotherapy services. You say that you were told that this 
provider was in-network. 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 a $725 out-of-network deductible which applies to out-of-network 
outpatient mental health care. 
 
 
 
 
 
 You have been asked to pay a $324.93 deductible for the psychotherapy services ($108.31 x 3 services = 
$324.93). The items or services you asked the Plan to waive the deductible for were provided by an out-of-
network provider. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$725 out-of-network deductible which applies to outpatient mental health care. This cost sharing is a 
contractual obligation that had not been met at the time the psychotherapy services were provided on January 
17, 2023, to January 31, 2023. Therefore, we decided that the Plan does not have to waive the deductible for 
the psychotherapy services provided by an out-of-network provider from January 17, 2023, to January 31, 
2023.
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 is in need of inpatient rehabilitation for 
medical complexities and therapy needs. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to an IRF.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after June 
22, 2023. 
 You asked the Plan to pre-approve SNF care after June 22, 2023. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care after June 22, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found the enrollee does not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care after June 22, 2023, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care after June 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Transcutaneous Electrical Nerve Stimulation (TENS) 
device (E0730) and supplies (A4595) provided on October 28, 2022. 
 
You asked the Plan to pay for the TENS device and supplies. The Plan denied your request. The Plan says the 
documentation included with the appeal does not indicate that the enrollee is enrolled in a clinical trial. The 
Plan says that therefore, the appeal request has been denied. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS therapy for Chronic Low Back Pain 
(CLBP) will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The record shows that the enrollees diagnosis appears to be pain in 
the thoracic spine and low back pain. Based on this information, we decided that Medicare rules for coverage 
of the TENS device and supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for the Transcutaneous Electrical Nerve Stimulation (TENS) device (E0730) and supplies (A4595) provided on 
October 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pain clinic visit provided on January 17, 2023. 
 
You asked the Plan to pay for a pain clinic visit. You say that this was medically necessary and should be 
covered. 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 a pain clinic visit 
provided on January 17, 2023.
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 are requesting an expedited reconsideration for 
the denial of an IRF admission as you feel the services provided by this IRF are critical in your aftercare and 
passion to live independently. The Plan denied your request. The Plan says you do not meet the Medicare 
criteria for admission to an IRF.  
 
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 your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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.