Persius/hicric huggingface dataset:
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 requires an IRF admission to regain 
maximum function. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on September 12, 2022. 
 
You asked the Plan to pay for injections. You say that you are requesting reconsideration for 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 
September 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) scan, 
treatment of root canal obstruction, and an unspecified endodontic procedure (D0380, D3999, D3331). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
cone beam computed tomography (CT) scan, treatment of root canal obstruction, and an unspecified 
endodontic procedure (D0380, D3999, D3331).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on July 11, 
2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the lab services should be 
covered under your annual office visit. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $40 copayment for the laboratory services. This item/service falls within the in-network 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 laboratory services provided on July 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for a cholecystectomy provided 
on April 14, 2022. 
 
You asked the Plan to waive the deductible and copayment for the cholecystectomy. You say that you did not 
receive a bill until December and your deductible had been met. 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 $1,000 deductible which applies to certain items and services. Your 
contract with the Plan also says that you must pay a $195 copayment for outpatient surgery at an ambulatory 
surgical center after the deductible is met. 
 
 The item or service you asked the Plan to waive the deductible and copayment for falls within the outpatient 
surgery at an ambulatory surgical center benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,000 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the cholecystectomy was received on April 
14, 2022.  
 
At the time of service, you had a total of $894.27 remaining to meet your deductible. Once this amount was 
met, the copayment of $175 was applied, which is less than the $195 copayment per the EOC. This means that 
you have been asked to pay the correct amount based on the contract with the Plan. Therefore, we decided that 
the Plan does not have to waive the deductible and copayment for a cholecystectomy provided on April 14, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nonadjunctive, nonimplanted continuous glucose 
monitor (CGM) or receiver (E2103) and a supply allowance for nonadjunctive CGM (A4239). 
 
You asked the Plan to pre-approve a nonadjunctive CGM and supplies. You say that the enrollee has had 
multiple strokes which makes it difficult to prick his finger to check his glucose. The Plan denied your request. 
The Plan says the enrollee does not meet criteria for approval of the CGM and supplies. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections, or the enrollee does not have history of repeated low blood sugars or low 
blood sugar that has required intervention. Based on this information, we decided that Medicare rules for 
coverage of a nonadjunctive CGM and supplies have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a nonadjunctive, nonimplanted continuous glucose monitor (CGM) or receiver 
(E2103) and a supply allowance for nonadjunctive CGM (A4239).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the cervical and thoracic spine x-rays 
provided on December 30, 2022. 
 
You asked the Plan to reduce the copayment for the cervical and thoracic spine x-rays. You say that you feel 
you should not be charged two 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). Your contract with the Plan clearly says that you must pay a $15 
copayment for each standard x-ray service. 
 
You have been asked to pay a $15 copayment for the cervical and thoracic spine x-rays. This item/service falls 
within the each standard x-ray service 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 you owe is $30 ($15 copayment x 2 x-ray services = $30). Therefore, 
we decided that the Plan does not have to reduce the copayment for the cervical and thoracic spine x-rays 
provided on December 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the myocardial perfusion imaging, 
tomographic (SPECT) provided on December 08, 2022. 
 
You asked the Plan to reduce the copayment for the myocardial perfusion imaging, tomographic (SPECT). You 
say that you thought your copayment was only $30 for this test. 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 $125 
copayment for advanced radiology services. 
 
You have been asked to pay a $125 copayment for the myocardial perfusion imaging, tomographic (SPECT). 
This item/service falls within the advanced radiology 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 reduce the copayment for the myocardial perfusion imaging, tomographic (SPECT) provided on December 
08, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening mammogram provided on January 10, 2023. 
 
You asked the Plan to pay for the screening mammogram. You say that the services were medically necessary. 
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 screening 
mammogram provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you never would have switched insurance if 
you knew it was going to be a problem. The Plan denied your request. The Plan says members may obtain 
services from an out-of-network provider only when providers of specialized services are not available In-
Network (i.e., a unique sub-specialty where the plan does not have a contracted provider), or in urgent and/or 
emergent situations. To obtain authorization for a provider of specialized services that are not available In-
Network, the enrollees primary care physicain (PCP) will submit a referral request and any supporting 
documentation to the enrollees assigned IPA/medical group. For any urgent or emergent services, the care may 
be provided first, and then a claim for those services submitted to the plan by the provider along with 
supporting medical documentation. 
 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 to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alveoloplasty (D7320). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
alveoloplasty (D7320).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a wearable defibrillator provided on 
October 21, 2022, to November 21, 2022. 
 
You asked the Plan to waive the coinsurance for a wearable defibrillator. You say that you cannot afford the 
cost sharing 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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for all other covered durable medical equipment items besides certain mobility devices. 
 
You have been asked to pay 20% coinsurance for a wearable defibrillator. This item/service falls within the all 
other covered durable medical equipment items besides certain mobility devices 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 $1232.38 
($6161.90 allowed amount for 2 months x 20% = $1232.38). Therefore, we decided that the Plan does not have 
to waive the coinsurance for a wearable defibrillator provided on October 21, 2022, to November 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on October 18, 2022. 
 
You asked the Plan to pay for laboratory testing. 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 laboratory testing 
provided on October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transport chair provided on August 02, 2022. 
 
You asked the Plan to pay for a transport chair. You say that you were hoping the plan would help and 
reimburse some of the cost. 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 transport chair 
provided on August 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on January 02, 
2023. 
 
You asked the Plan to pay for principal care management services. You say that you did not have any input in 
choosing who would be the 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 principal care 
management services provided on January 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you say the doctor you've seen for 3 years is no 
longer in network and would like to see a new one. The Plan denied your request. The Plan says members may 
obtain services from an out-of-network provider only when providers of specialized services are not available 
In-Network (i.e., a unique sub-specialty where the plan does not have a contracted provider), or in urgent 
and/or emergent situations. To obtain authorization for a provider of specialized services that are not available 
In-Network, the enrollees primary care physicain (PCP) will submit a referral request and any supporting 
documentation to the enrollees assigned IPA/medical group. For any urgent or emergent services, the care may 
be provided first, and then a claim for those services submitted to the plan by the provider along with 
supporting medical documentation. 
 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 to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on May 26, 
2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you were seen at the urgent 
care center while in Pennsylvania. 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 $30 
copayment for urgently needed services. 
 
You have been asked to pay a $30 copayment for the urgent care visit. This item/service falls within the 
urgently needed 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. Please note that the Plan reprocessed the claim to apply the correct copayment for the visit. 
Therefore, we decided that the Plan does not have to waive the copayment for the urgent care visit provided on 
May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on December 8, 
2022. 
 
You asked the Plan to waive the deductible for the office visit. You say that you thought the services were fully 
covered. 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 an $800 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the doctor and other health care 
provider services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is an $800 deductible which applies to certain items and services. This cost sharing is a contractual 
obligation that had not been met at the time the office visit was received on December 8, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible for an office visit provided on December 8, 2022.