Persius/hicric huggingface dataset:
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 
October 27, 2022, to November 3, 2022, the lab services provided on January 12, 2023, and the inpatient 
hospital stay provided from January 21, 2023, to January 27, 2023. 
 
You asked the Plan to waive the copayment for the two inpatient hospital stays and the lab services. You say 
that you think that you were billed incorrectly. 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 $315 
copayment per day, for days 1-6, per hospital stay in 2022, a $340 copayment per day, for days 1-6, per 
hospital stay in 2023, and a $10 copayment for bloodwork drawn at a physicians office and sent to an 
independent lab for processing. 
 
You have been asked to pay a $1890 copayment for the inpatient hospital stay provided from October 27, 2022, 
to November 3, 2022 ($315 x 6 days = $1890). You have been asked to pay a $1360 copayment for the 
inpatient hospital stay provided from January 21, 2023, to January 27, 2023 ($340 x 4 days = $1360). These 
items/services fall within the inpatient hospital care benefit category. You have also been asked to pay a $10 
copayment for the lab services. These items/services 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 copayment for the inpatient 
hospital stay provided from October 27, 2022, to November 3, 2022, the lab services provided on January 12, 
2023, and the inpatient hospital stay provided from January 21, 2023, to January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is diagnosed with severe COPD 
and chronic respiratory failure with hypoxia. The device is medically necessary. The Plan denied your request. 
The Plan says the enrollee does not meet criteria for approval of the requested ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the Life 2000 home ventilator is being requested for use with very low set tidal which is a modality which 
could be provided by a bilevel positive airway pressure (BiPAP) device with average volume assured pressure 
support (AVAPS) and a back-up rate. Provided records do not document trial and failure of a BiPAP device 
with AVAPS and a back-up rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for outpatient services on January 18, 2023.  
 
You asked the Plan to waive the deductible for outpatient services. You say that you shouldn't have to pay. 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 $750 deductible which applies to outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 
This cost sharing is a contractual obligation that had not been met at the time outpatient services was received 
on January 18, 2023. Therefore, we decided that the Plan does not have to waive the deductible for outpatient 
services on January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on February 15, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the vision services. You say that at the time services were provided the enrollee 
was residing in a nursing facility. The Plan denied your request. The Plan says the 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 vision services provided on February 15, 2023, 
by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the remote interrogation device evaluations 
provided on February 24, 2023. 
 
You asked the Plan to waive the copayment for the remote interrogation device evaluations. You say that you 
do not think that there is 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 $25 
copayment for each Medicare-covered other diagnostic test. 
 
 You have been asked to pay a $49.27 copayment for the remote interrogation device evaluations because the 
allowed amount for one of the services is less than the $25 copayment. These items/services 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 copayment for the remote interrogation device evaluations provided on February 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional forty-eight (48) non-emergent routine 
transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
transportation trips due to change in your health status. The Plan denied your request. The Plan says additional 
trips would exceed your benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that you have used 
forty-three (43) one-way transportation trips out of the allowed forty-eight (48) one-way trips approved. Once 
48 trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve an additional forty-eight (48) non-emergent routine transportation trips (A0120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation does not reveal the rationale for this invasive imaging study. 
Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this time cardiac 
catheterization would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization (93458).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulmonary diagnostic testing and therapies provided on 
December 22, 2022. 
 
You asked the Plan to pay for pulmonary diagnostic testing and therapies. You say that you are requesting the 
submitted documentation be reviewed. 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 pulmonary diagnostic 
testing and therapies provided on December 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99214) and surgery of intracranial 
arteriovenous malformation (61682) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit and surgery of intracranial arteriovenous malformation to be 
provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan 
says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not 
been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99214) and surgery of intracranial arteriovenous malformation (61682) to be provided 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 portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the item is necessary. The Plan 
denied your request. The Plan says the item is being requested for travel and therefore, is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient psychiatric stay provided from 
March 15, 2023, to March 17, 2023. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that you do not understand the cost 
sharing. 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 $245 
copayment per day, days 1 to 5, for inpatient psychiatric facility stays. 
 
 
 You have been asked to pay a $490 copayment for the inpatient stay ($245 x 2 days = $490). This item/service 
falls within the inpatient services in a psychiatric hospital 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 psychiatric stay provided from March 15, 2023, to March 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on December 26, 2022. 
 
You asked the Plan to pay for wound care. You say that you say that the assisted living facility was responsible 
for authorization. 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 wound care provided on 
December 26, 2022.
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 20, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you do not agree with the 
copayment applied to 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 $60 
copayment for in and out-of-network visits to a medical facility or urgent care center. 
 
You have been asked to pay a $60 copayment for an office visit. This item/service falls within the in and out-
of-network visits to a medical facility or urgent care center 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 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care treatment provided on December 5, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for wound care treatment. You say that the assisted living facility is responsible to 
obtain prior authorization for all of their patients. 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 wound care treatment provided on December 5, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on January 10, 2023. 
 
You asked the Plan to pay for injections. You say that the records attached support the services provided. 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 injections provided on 
January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941), office visit 
(99202), and the electric stimulation therapy (97014) provided from February 14, 2023, through March 15, 
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 payable as prior 
authorization was not provided.  
 
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 chiropractic manipulative treatments provided in this case were not prior authorized 
by the Plan. Additionally, the Plan contract states that the only covered chiropractic service is manual 
manipulation of the spine to correct a subluxation.  
  
 
 
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941), 
office visit (99202), and the electric stimulation therapy (97014) provided from February 14, 2023, through 
March 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on March 21, 2023, to 
March 23, 2023. 
 
You asked the Plan to pay for subsequent hospital care. You say that an authorization was requested. 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 subsequent hospital care 
provided on March 21, 2023, to March 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on March 26, 2023. 
 
You asked the Plan to pay for home visit. 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 home visit provided on 
March 26, 2023.