Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker provided on June 9, 2020. 
 
You asked the Plan to pay for this item. You say that the provider told you the Plan should pay for this walker. 
The Plan denied your request. The Plan says this provider is not a Medicare eligible provider and you did not 
have prior authorization. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program. The 
Plan contract says that durable medical equipment requires prior authorization.  
 
The services at issue in this appeal were provided by the provider who has opted out of the Medicare program 
and without prior authorization. Therefore, we decided that the Plan does not have to pay for a walker provided 
on June 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGel-One.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has left knee pain due to osteoarthritis. She has not tried and failed the Plan's required drugsof Euflexxa, Supartz F/X, Durolane, or Gelsyn-3. The records do not show that the required drugs would be contraindicated or less effective; therefore, Gel-One is not reasonable or medically necessary. 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 not been met.Therefore, we decided that the Plan does not have to pre-approveGel-One.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulatory surgery care for cataract removal provided on 
December 3, 2019. 
 
You asked the Plan to pay for the ambulatory surgery care. You say that the enrollee presented with Medicare 
and you were not able to get authorization. The Plan denied your request. The Plan says the Plan did not make 
a timely decision. 
 
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 did not pre-approve the 
ambulatory surgery care for cataract removal. We found no exception that would require the Plan to pay for 
these services. Therefore, we decided that the Plan does not have to pay for ambulatory surgery care for 
cataract removal provided on December 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the inpatient hospital care provided from 
January 10, 2020, through January 13, 2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment per day, for days 1-7 for inpatient hospital care.  
 
You have been asked to pay $675 ($225 copayment x 3 days) for the inpatient hospital care provided. 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 adjust the copayment for the inpatient hospital care provided from January 10, 2020, 
through January 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on April 9, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 9, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on April 
9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric services rendered by the out of 
network (OON) provider from July 1, 2020, through July 3, 2020. 
 
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 the services were rendered by an out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the inpatient psychiatric services rendered by the out of network (OON) 
provider from July 1, 2020, through July 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Meropenem IV. 
 
You asked the Plan to pre-approve Meropenem IV. You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Meropenem IV.  
 
Benefits for Meropenem IV may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 2, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
physicians services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on August 3, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for outpatient hospital services. You say that you had no idea the woman was a 
private contractor. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan 
says that there are in-network providers available. 
 
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 has network providers 
available who can provide 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 outpatient hospital services provided on August 3, 
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0220) and the full cast high noble 
metal crown (D2790) provided on July 16, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were not advised that the services would 
not be covered. You also say that you were not given a pre-treatment estimate for the crown. The Plan denied 
your request. The Plan says periapical x-ray is not listed as a covered service. The Plan says full cast high noble 
metal crown is not listed as a covered service either. The Plan also says 
 
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 dental services you received are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periapical x-ray (D0220) and the full cast high noble metal crown (D2790) provided on July 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
January 17, 2018, through January 24, 2018. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 a $225 
copayment per day, for days 1-7 for inpatient hospital care.  
 
You have been asked to pay $1,575 ($225 copayment x 7 days) for the inpatient hospital care provided. 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 care provided from January 17, 2018, 
through January 24, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve food thickener, administered orally, per ounce (B4100). 
 
You asked the Plan to pre-approve the food thickener. You say that please approve the food thickeners for this 
enrollee in order to reduce her risk of future hospitalizations and morbidity. The Plan denied your request. The 
Plan says nutritional supplementation is not covered under Medicare Part B. The plan overturned and agreed to 
cover under the Medicaid portion of this plans benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan 
does not have to pre-approve food thickener, administered orally, per ounce (B4100).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care provided to the enrollee from January 7, 
2020, to January 28, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the claims were submitted with inappropriate home health data. The Final claim with the 
correct HHRG code is required to process and pay claims.  
 
 
The HHRG code on the claims indicates there were Non-Routine Supplies (NRS) provided but are not 
submitted on the claim and submitted HIPPS code is invalid; therefore, per the Medicare guidelines the plan is 
upholding the claim denials as the provider did not bill appropriately.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted cannot be paid as 
billed due to inappropriate or omitted codes on the claim. The Plan states a corrected claim would be reviewed. 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for home health care provided to the enrollee from January 7, 2020, to January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on July 9, 2020. 
 
You asked the Plan to pay for these services. You say that this visit should be covered by the Plan. The Plan 
denied your request. The Plan says the services billed are not covered by Medicare. 
 
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 service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided on July 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the nephrology services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the OON nephrology services. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent 
nor urgent to seek out-of-network care. The Plan says there are in-network nephrology specialists available to 
you that can provide the services you are requesting. 
 
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 
the nephrology services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided on June 8, 2020. 
 
You asked the Plan to pay for self-administered drugs under Medicare Part B. You say that this claim should be 
covered by the Plan. The Plan denied your request. The Plan says self-administered drugs must be submitted to 
Medicare Part D for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on June 8, 2020.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from May 
22, 2020, to August 10, 2020. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were told that the 
charges would be covered. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
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 received Medicare Part B drugs from May 22, 2020, to August 10, 2020. Therefore, you are responsible to 
pay your share of the cost-sharing charges. Please see the chart below.  
 
 
Date of Service Service Code Allowed Amount  Amount You Owe 
5/22/2020 J2505 $3,983.15 $796.63 
6/05/2020 J2505 $3,983.15 $796.63 
6/17/2020 J2505 $368.88 $63.74 
6/19/2020 J2505 $3,983.15 $796.63 
7/6/2020 964113 $344.56 $58.88 
7/08/2020 J2505 $3,807.30 $761.46 
7/22/2020 J2505 $344.56 $58.88 
7/27/2020 Q5111 $3,621.60 $724.32 
 
 
8/5/2020 96413 $228.87 $41.71 
8/10/2020 Q5111 $3,621.60 $724.32 
 
The total amount you owe is: $4,823.20.  
 
You have been asked to pay the total coinsurance amount of $4,823.20 for Medicare Part B drugs. Medicare 
Part B drugs fall 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. Therefore, we decided that the Plan does not have 
to waive the coinsurance for Medicare Part B drugs provided from May 22, 2020, to August 10, 2020.
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 records provided support the need for care in an
IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.
The Plan says that the enrollee can safely receive the services needed in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for conservative management of bilateral proximal humeral fractures after a fall. The enrollee's
medical problems are stable. There are no identified problems that need inpatient medical management. There
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The
medical record supports a need for physical and occupational therapy, but it does not support a need for an
intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 11, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 11, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on August 11, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance charged for outpatient mental health care 
provided out of network from June 24, 2020, to July 1, 2020. 
 
You asked the Plan to waive this service. You say that you did not know this provider was out of network. The 
Plan denied your request. The Plan says this coinsurance was charged based on the services provided and the 
Plan contract agreement. 
 
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 40% 
coinsurance for out of network outpatient mental health care. 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 coinsurance charged for 
outpatient mental health care provided out of network from June 24, 2020, to July 1, 2020.