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

 
We decided that the Plan does not have to waive the copayment for the office visit provided on May 17, 2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that this was an annual wellness visit 
and should not be charged 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 $10 
copayment for an in-network PCP visit.  
 
The record shows you are not being charged for the annual wellness visit. You have been asked to pay a $10 
copayment for the office visit. This item/service falls within the physician/practitioner services, including 
doctors office visits 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 office visit 
provided on May 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on June 
29, 2023. You asked the Plan to waive the copayment for the ambulance services. You say that you are requesting further 
explanation on the cost share applied to this claim. 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 for each Medicare-covered trip.  
 
You have been asked to pay a $245 copayment for the ambulance services. 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 
services provided on June 29, 2023.  
 
Please note that neither you nor the Plan are responsible for paying the balance bill. Please contact the 
provider about a refund for any amount you paid above the Medicare allowable amount for the urgent care 
visits. If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the 
Plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum pump (L5781) feature for an approved 
prosthetic. 
 
You asked the Plan to pre-approve the vacuum pump. You say that this feature is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has 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 the vacuum pump. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support the need for the elevated vacuum suspension system with 
the already approved suction socket. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the vacuum pump have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a vacuum pump (L5781) feature for an approved prosthetic.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (G0452, 87500, 87641, 87798, 87491, 
87496, 87511, 87529, 87532, 87563, 87591, 87661, 87481, 87651 and 87653) billed for date of service July 3, 
2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this was a single test panel which was not 
billed with one panel code as instructed by Medicare rules. 
 The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory panel (G0452, 87500, 87641, 87798, 87491, 87496, 87511, 87529, 
87532, 87563, 87591, 87661, 87481, 87651 and 87653) billed for date of service July 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulation (PNS) system 
(64555). 
 
You asked the Plan to pre-approve a Sprint PNS system. 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 a Sprint PNS system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient literature to support the safety and efficacy, as defined by 
Medicare rules, of the requested service. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. The requested service is not recommended. 
 
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 Sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Sprint peripheral nerve stimulation (PNS) system (64555).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital admission provided on June 10, 2023, 
through June 11, 2023. 
 
You asked the Plan to pay for an inpatient hospital admission. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the enrollee was admitted for confusion, likely secondary to baclofen 
overuse. The enrollee does not meet criteria for approval of an inpatient admission. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for an inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for an inpatient hospital admission was 
met in this case. Our physician reviewer found the enrollee was admitted for observation (as noted in the 
documentation) for an altered mental status, likely secondary to baclofen overuse. The enrollee stayed in the 
hospital one night and was then discharged. This was not an inpatient admission. 
 
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 inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pay for an inpatient hospital admission provided on June 10, 2023, through June 11, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray provided on July 31, 2023. 
 You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says the x-ray was provided 
for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The imaging at issue in this appeal, the x-ray, was requested solely for screening purposes. Medicare does not 
cover this imaging solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the x-ray provided on July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (AWV) provided on July 7, 2023. 
 
You asked the Plan to pay for the AWV. The Plan denied your request. The Plan says the benefit limit has been 
exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for the annual wellness visit (AWV) provided on July 
7, 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 need IRF services as you have no energy or 
strength. The Plan denied your request. The Plan says you do not meet the requirements for an IRF admission.  
 
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 your nursing, medical, and rehabilitation needs can be provided at 
a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can be provided in a lower 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided October 5, 2022, to 
October 6, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says the notes do not say the enrollee did not get 
better within 48 hours. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission it was reasonable for the admitting physician to expect that the enrollees necessary hospital care 
(including earlier emergency department and/or observation care) would span two midnights with supporting 
documentation of the enrollees history and comorbidities, signs and symptoms, current medical needs, and risk 
of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided October 5, 2022, to October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 13, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that this was a follow-up visit from March where several 
skin lesions were removed. The Plan denied your request. The Plan says the services are not a covered benefit 
when received by an OON provider. 
 
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 office visit provided on September 13, 2023, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injections provided on October 26, 
2022. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you should have no copayment for 
this service and the service should be 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 (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 the injections. 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 total you owe is $270.12 ($1,350.60 allowed amount x 20% = $270.12). Therefore, 
we decided that the Plan does not have to waive the coinsurance for the injections provided on October 26, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the whirlpool/spa received on August 11, 2023. 
 You asked the Plan to pay for the whirlpool/spa. You say that this is medically necessary equipment that was 
prescribed by your physician and has a positive impact on your health condition. The Plan denied your request. 
The Plan says the item received 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. Whirlpool bath equipment is only covered when the enrollee is homebound. 
 
Review of the file does not support that you are homebound. No medical records were provided to support the 
need of the item received. Therefore, we decided that the Plan does not have to pay for the whirlpool/spa 
received on August 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided on July 28, 
2023. 
 
You asked the Plan to pay for evaluation and management services. You say that it was not possible to request 
authorization before services. 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 evaluation and 
management services provided on July 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a disposable drug delivery system and supplies provided 
from June 6, 2023, to July 12, 2023. 
 
You asked the Plan to pay for disposable drug system. You say that the Plan's denial is erroneous. The Plan 
denied your request. The Plan says these supplies are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems and associated 
supplies are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of disposable drug system have not been met. Therefore, we decided that the Plan does not have to 
pay for a disposable drug delivery system and supplies provided from June 6, 2023, to July 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the bone debridement procedure provided 
on February 27, 2023 
 
You asked the Plan to waive the copayment for the bone debridement procedure. You say that you were told 
you would not be billed 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 $275 
copayment for outpatient procedures and services, including outpatient surgery with a preferred provider.  
 
 You have been asked to pay a $275 copayment for the bone debridement procedure. This item/service falls 
within the outpatient surgery 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 bone 
debridement procedure provided on February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on July 26, 2023. 
 
You asked the Plan to pay for the wound care services. 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 wound care services 
provided on July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99205) for a heart transplant evaluation, 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that due to the enrollee's critical state, you would 
like to evaluate the enrollee's option of a heart transplant. The Plan denied your request. The Plan says the 
enrollee must use network providers to get medical care and services. The Plan also says the service requested 
is available with an in-network provider. 
 
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 (99205) for a heart transplant evaluation, 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 pay for a follow-up appointment provided on September 6, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for physician services. You say that these services were necessary. The Plan denied 
your request. The Plan says that their original decision to deny payment was correct. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out-of-area urgent care, and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a follow-up appointment provided on September 
6, 2023, by an OON provider.