Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the Medicare criteria for LTACH services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency surgery and services provided from January 17, 2023, to 
January 23, 2023 at a foreign hospital.  
You asked the Plan to pay for the emergency surgery and services. The Plan denied your request. The Plan says 
that the emergency services denied because in addition to submitting a claim form for the services you received 
while out the country, a receipt or proof of payment is needed that shows you paid for the services on the claim 
form you submitted. 
 
The Plan must follow Medicare rules. The rules say that items and services furnished outside the United States 
are excluded from coverage except for the services listed in the Medicare rules section of this letter. The rules 
also 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. Specifically, the Plans denial reason is that they did not receive receipt or proof 
of payment. However, the case file includes multiple receipts for services/items provided during the dates of 
service in dispute. Therefore, the Plan has not substantiated their denial in this case. Therefore, we decided that 
the Plan has to pay for the emergency surgery and services provided from January 17, 2023, to January 23, 
2023 at a foreign hospital.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic tests provided on 
May 10, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic tests. You say that you disagree with 
the 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 outpatient diagnostic tests/Medicare-covered EKG. 
 
You have been asked to pay a $35 copayment for an outpatient diagnostic tests. This item/service falls within 
the outpatient diagnostic tests/Medicare-covered EKG 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. However, you are only being asked to pay $14.39 which is 
less than the required amount. Therefore, we decided that the Plan does not have to waive the copayment for an 
outpatient diagnostic tests provided on May 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the orthotic device provided on June 21, 
2022. 
 
You asked the Plan to waive the coinsurance for the orthotic device. You say that you did not know about this 
coinsurance, and the device did not work. 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 in-network durable medical equipment an related supplies. 
 
You have been asked to pay 20% coinsurance for the orthotic device. This item/service falls within the in-
network durable medical equipment an related 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. The total you owe is $167.93 ($839.64 allowed amount x 
20% coinsurance = $167.93). Therefore, we decided that the Plan does not have to waive the coinsurance for 
the orthotic device provided on June 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the radioactive material injection provided 
on April 03, 2023. 
 
You asked the Plan to waive the copayment for the radioactive material injection. You say that you had no say 
in who provided 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 $300 
copayment for in-network outpatient surgery provided at an outpatient hospital. 
 
You have been asked to pay a $300 copayment for the radioactive material injection. This item/service falls 
within the in-network outpatient surgery provided at an outpatient 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. The records show the injection was 
provided at an outpatient hospital, and was processed as in-network. Therefore, we decided that the Plan does 
not have to waive the copayment for the radioactive material injection provided on April 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
system. 
 
You asked the Plan to pre-approve the CGM. The Plan denied your request. The Plan says a CGM is not 
covered under Medicare if the enrollee is not on insulin or does not have documentation of recurrent 
problematic hypoglycemia. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the CGM have been met. We were 
unable to determine who the requestor for this case. Without this information we are unable to proceed with 
this request. The Plan has shown that they made reasonable attempts to the providers office to obtain this 
necessary information. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
continuous glucose monitor (CGM) system.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 24-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to 
medical appointments. The Plan denied your request. The Plan says you have exhausted your transportation 
benefit. 
 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 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
24-trip limit.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99284) provided on April 
22, 2023. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says 
CPT 99284 is not eligible for payment due to a detailed exam and history was not rendered and the presenting 
problem was not a high-risk threat. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 In this case, the CPT Code Manual definition of code 99284 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
We asked our coder 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 the emergency department visit. Our reviewer found there 
was no detailed history and physical performed and no moderate level of decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay for the emergency department visit (99284) provided on April 22, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from December 30, 2022, 
through January 9, 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 that the acute inpatient hospital care provided 
was not medically necessary.  
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the documentation indicates that the enrollee presented on December 30, 2022 with acute on chronic 
asymptomatic hyponatremia in addition to several other vague complaints concerning for polypharmacy. The 
course was complicated by asymptomatic hypotension for which she was transferred to the Progressive Care 
Unit (PCU) but remained stable. The review has determined that the record showed that at the time of the 
inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care 
(including earlier emergency department (ED) and/or observation care) would span two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from December 30, 2022, through January 9, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
February 15, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you did not receive an 
ultrasound on this date. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $50 copayment for the specialist office visit. This item/service falls within the 
in-network specialist physician/practitioner services benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The records shows you are only being asked to pay for the office 
visit, not an ultrasound. Therefore, we decided that the Plan does not have to waive the copayment for the 
specialist office visit provided on February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on April 28, 2023. 
 
You asked the Plan to pay for a facility visit. You say that this patient is in a facility, and you depend upon the 
facility staff for any verification or prior 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 a facility visit provided 
on April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on April 
17, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you tried to see your 
primary care provider, and feel you should only have to pay the $10 primary care provider office visit 
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 $40 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
specialist physician/practitioner services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. The records show you were seen by a specialist on April 17, 2023. 
Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit 
provided on April 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia provided on April 11, 2023. 
 
You asked the Plan to pay for the anesthesia. 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 anesthesia provided 
on April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on April 22, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration stating that the 
services were medically necessary and you have submitted medical documentation to support. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
April 22, 2023.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Vabysmo intravitreal injections. 
 
You asked the Plan to pre-approve Vabysmo intravitreal injections. You say that the enrollee is at risk of 
possible vision loss. The Plan denied your request. The Plan says that that the step therapy requirements have 
not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. If a Plan decides to apply step therapy requirements to Part B drugs, they must 
disclose that information in the ANOC and EOC documents. The Plan's contract does not indicate that it has 
implemented such criteria for certain Part B medications. 
 
We looked at your contract with the Plan. We did not see where the contract says that the Plan has decided to 
apply step therapy requirements to Part B drugs. This means that the Plan did not follow Medicare rules for 
disclosure of step therapy information. Therefore, we decided that the Plan has to pre-approve Vabysmo 
intravitreal injections.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visits and the euflexxa 
injections provided on January 24, 2023, to February 7, 2023 
 
You asked the Plan to waive the cost share for the specialist office visits and the injections. You say that you 
disagree with the 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 a specialist office visit. Your contract with the Plan also clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs. 
 
You have been asked to pay a $35 copayment for each specialist office visit provided on January 24, 2023, 
January 31, 2023, and February 7, 2023. These items/services fall within the doctor's 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.  
 
You have also been asked to pay $25.92, which is 20% coinsurance of the allowed amount for each injection 
provided on January 24, 2023, and February 7, 2023 ($129.58 allowed amount x 20% = $25.92). You have also 
been asked to pay $26.18, which is 20% coinsurance of the allowed amount for the injection provided on 
January 31, 2023 ($130.89 allowed amount x 20% = $26.18). These items/services fall within the Medicare 
Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the cost share for the specialist office visits 
and the euflexxa injections provided on January 24, 2023, to February 7, 2023
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77067 and 77063 billed for date of service 
March 21, 2023.  
 You asked the Plan to pay for procedure codes 77067 and 77063. You say that this should be paid. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77067 is 1 unit. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Because code 77063 is an add-on code, it cannot be paid when 77067 is not paid. 
Based on this information, we decided that Medicare rules for coverage of procedure codes 77067 and 77063 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 77067 and 
77063 billed for date of service March 21, 2023.