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

 
We decided that the Plan does not have to pay for remote monitoring services provided on May 23, 2023, to 
May 31, 2023. 
 
You asked the Plan to pay for remote monitoring services. You say that this was a highly medically necessary 
and should be covered. Please note that this was the only provider available at the time. 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 remote monitoring 
services provided on May 23, 2023, to May 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by an 
in-network provider from April 25, 2023, to May 3, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not think the 
enrollee should be liable. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $325 copayment per day, days 1-6, for each in-network Medicare-covered hospital admission.   
 
 The enrollee has been asked to pay a $1950 copayment for the inpatient hospital stay ($325 copayment x 6 
days = $1950). This item/service falls within the inpatient hospital care 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 the inpatient hospital stay provided by an in-network provider from 
April 25, 2023, to May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit and debridement provided on June 08, 2023. 
 
You asked the Plan to pay for the home visit and debridement. You say that you are appealing the denial with 
supporting documentation. 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 home visit and 
debridement provided on June 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unlisted procedure, male genital system (55899) and 
a cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor and incisional 
struts (C9769). 
 
You asked the Plan to pre-approve an unlisted procedure and a cystourethroscopy. You say that the requested 
procedure is a minimally invasive surgical intervention and is medically necessary and clinically indicated for 
this enrollee. The Plan denied your request. The Plan says there are not enough studies on the requested 
procedure to show it is safe and effective. 
 
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 an unlisted procedure and a 
cystourethroscopy. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the use of a temporarily implanted nitinol device (e.g., 
iTind) is considered investigational as a treatment of lower urinary tract symptoms due to benign prostatic 
hyperplasia. Further studies are needed to evaluate the durability of iTIND outcomes over a longer follow-up, 
to better define the indications of this approach, and to demonstrate the advantages of second-generation device 
over the first device. ITind is not recommended in the most recent American Urological Association (AUA) 
Guidelines regarding treatment of benign prostatic hyperplasia (BPH). 
 
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 unlisted procedure and a cystourethroscopy have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an unlisted procedure, male genital system (55899) and a 
cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor and incisional struts 
(C9769).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on May 08, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that you are requesting reconsideration of the denied 
claim. 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 psychotherapy 
provided on May 08, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient hospital stay 
provided from July 22, 2022, to July 24, 2022. 
 
You asked the Plan to waive the copayment for an in-network inpatient hospital stay. You say that you had 
terrible service here and had to be transferred to a different facility. You should not have to pay a copayment 
for this service. 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 $225 
copayment each day for days 1 to 7 for inpatient hospital services.  
 
You have been asked to pay a $450 total copayment for an in-network inpatient hospital stay ($225 x 2 days = 
$450). This item/service falls within the inpatient 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. Therefore, we decided that 
the Plan does not have to waive the copayment for an in-network inpatient hospital stay provided from July 22, 
2022, to July 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for whirlpool tub provided on February 17, 2023. 
 
You asked the Plan to pay for whirlpool tub. You say that the services 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 whirlpool tub provided 
on February 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
May 8, 2023, to May 24, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the enrollee was asked 
to pay more than the maximum out-of-pocket amount. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $150 copayment per day for days 1-5 of each inpatient hospital stay. The enrollees contract with 
the Plan also clearly says that enrollees then pay a $0 copayment for any additional days of the same inpatient 
hospital stay. 
 
The record shows the maximum out-of-pocket amount was processed correctly. The enrollee has been asked to 
pay a $150 copayment per day for days 1-5 of the inpatient hospital stay. The enrollee has been asked to pay a 
total of $750 for the inpatient hospital stay ($150 copayment per day x 5 days = $750). This item/service falls 
within the inpatient hospital care 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 the inpatient hospital stay provided from May 8, 2023, to May 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp (E1399) 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that the ramp is needed because the enrollee 
has mobility problems, prostate cancer, diabetes and is very weak. The enrollee is no longer able to perform 
daily activities without assistance. The Plan denied your request. The Plan says a wheelchair ramp is not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp (E1399)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service March 26, 
2023, to April 22, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like the Plan to reconsider their 
denial of payment. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service March 26, 2023, to April 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MRI provided on June 30, 2022, by an OON provider.  
 
You asked the Plan to pay for the MRI. You say that you are requesting reconsideration of the denied claim. 
The Plan denied your request. The Plan says the service was 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 the MRI provided on June 30, 2022, by an OON 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on April 18, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you think that there should not be a 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for in-network Medicare-covered podiatry visits in an office or home setting. 
 
You have been asked to pay a $35 copayment for an office visit. This item/service falls within the in-network 
Medicare-covered podiatry visits in an office or home setting 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 office visit provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on May 9, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the wound care supplies. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was 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 the wound care supplies provided on May 9, 2023, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and related services provided on June 28, 
2023. 
 
You asked the Plan to pay for an office visit, and related services. You say that authorization was not required. 
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 an office visit, and 
related services provided on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for each injection drug provided on May 04, 
2023, to June 01, 2023. 
 
You asked the Plan to reduce the coinsurance for each injection drug. You say that you disagree with the cost 
share increase. 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 each injection drug. 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. The amount you owe for each injection drug is $26 ($130 allowed amount x 
20% = $26). The total amount you owe is $52 ($26 coinsurance + $26 coinsurance = $52). Therefore, we 
decided that the Plan does not have to reduce the coinsurance for each injection drug provided on May 04, 
2023, to June 01, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99285 for date of service April 27, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that this exact service was already billed for this enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan states that this code was already billed for 
this enrollee for this billed date of service by this same provider. We looked at the file and Medicare rules. We 
find that the file does not include sufficient evidence to support the Plans argument that the claim at issue is a 
duplicate. The Plan did not include documentation to show this code previously processed by the Plan. 
Therefore, we decided that the Plan has to pay for procedure code 99285 for date of service April 27, 2023.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF visit provided from March 3, 2023, 
to March 24, 2023. 
 
You asked the Plan to waive the copayment for a SNF visit. You say that you were informed the cost share 
would only be $15. 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 $0 
copayment for days 1 to 20 and a $160 copayment per day for days 21 to 100 for SNF care.  
 
 
  You have been asked to pay a $160 copayment for a SNF visit. This item/service falls within the SNF 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 a SNF visit provided from 
March 3, 2023, to March 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the tear duct repair procedure provided on 
June 15, 2023. 
 
You asked the Plan to reduce the copayment for the tear duct repair procedure. You say that you do not feel 
this cost share is appropriate. 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 $275 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $275 copayment for the tear duct repair procedure. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 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 reduce the copayment for the tear duct repair procedure provided on June 15, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance transportations provided on 
March 4, 2023, and March 6, 2023. 
 
You asked the Plan to waive the copayments for the ambulance transportations. You say that the enrollee 
cannot afford the copayments. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $275 copayment for in-network. Medicare-covered ambulance services. 
 
 
 The enrollee has been asked to pay a $275 copayment for the ambulance transportation provide don March 4, 
2023. The enrollee has also been asked to pay $207.02, which is less than the standard copayment for the 
ambulance transportation provided on March 6, 2023. These 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 copayments for the ambulance transportations 
provided on March 4, 2023, and March 6, 2023.