Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from July 
8,2020, through August 6, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that the cost is unfair, and you 
should be reimbursed. The Plan denied your request. The Plan says the copayment applied 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 per visit, one copayment per date of service, per provider for each type of service. 
 
You have been asked to pay a $30 copayment for each physical therapy visit. The total amount you owe is 
$300 ($30/visit x 10 visits = $300). Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided from July 8,2020, 
through August 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on June 11, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that the services provided were medically necessary. 
The Plan denied your request. The Plan says the provider is not a TruHearing provider and therefore 
coverage is not provided. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only this benefit is limited to the TruHearing Advanced and Premium hearing aids. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were provided and is not TruHearing. Based on this information, we decided that the Plan's rules for coverage of the 
hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids 
provided on June 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 based on the medical records provided the complexity of the patient's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but 
based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy 
program. Based on the medical records provided there is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF due to poor 
endurance and poor exercise tolerance. Care at the skilled nursing facility level appears to be more appropriate 
in this case. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve elbow, wrist, hand, finger device, powered, with single 
or double upright(s), any type joint(s), includes microprocessor, sensors, all components and accessories (CPT 
Code L8702). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because this device has deluxe features that 
exceeds the member's needs and replaces, rather than improves the function of their arm. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the literature in the peer reviewed publications is not sufficient at this time to assess safety, long 
term outcomes and efficacy of the use of the MyoPro Orthosis for upper extremity paralysis/paresis. At the 
current time the literature small sample size, uncontrolled as well as prospective studies. Additional studies 
with larger cohorts with long term follow to assess safety and efficacy of this device for weakness of the 
extremity due to nerve damage such as this patient's condition. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve elbow, wrist, hand, finger device, powered, with single or double upright(s), any type joint(s), 
includes microprocessor, sensors, all components and accessories (CPT Code L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and the additional 
periapical x-rays (D0230 x 3) provided on August 20, 2020. 
 
You asked the Plan to pay for the dental services. You say that you had a dental appointment for routine x-rays 
and a cleaning. You say that your book says routine x-rays and cleaning are covered with a $0 copayment. You 
say that you do not remember reading anything about specific x-rays being covered or not. You also say that 
the services should be covered as you used your insurance the way you thought that you could. The Plan denied 
your request. The Plan says periapical x-rays are not listed as covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the periapical x-rays that you received 
are not among those covered under this benefit. Additionally, the Evidence of Coverage clearly states that any 
services not listed are not covered. Therefore, we decided that the Plan does not have to pay for the initial 
periapical x-ray (D0220) and the additional periapical x-rays (D0230 x 3) provided on August 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fine needle aspiration provided August 6, 2020. 
 
You asked the Plan to pay for a fine needle aspiration. The Plan denied your request. The Plan says 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. 
 
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 
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 a fine needle aspiration provided August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the office visit provided on February 19, 
2020. 
 
You asked the Plan to reduce the copayment for the office visit. You say that the claim is processing out-of-
network, but the provider is in-network. You say that there should only be a $10 copayment for a PCP visit. 
The Plan denied your request. The Plan says the copayment applied 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 $20 
copayment for services obtained from an out-of-network primary care provider or under certain circumstances, 
treatment by a nurse practitioner or physician?s assistant or other non-physician health care professionals in a 
primary care provider?s office.  
 
You have been asked to pay a $20 copayment for the office visit. The office visit 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 reduce the copayment for the office visit provided on February 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 based on the medical records provided the complexity of the patient's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but 
based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy 
program. Based on the medical records provided there is no documentation that the patient requires the 
intensive rehabilitation therapy program provided in an IRF. Care at the skilled nursing facility level appears to 
be more appropriate in this case. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the golf outings played from January 6, 2020, to 
June 2, 2020. 
 
You asked the Plan to reimburse you for the golf outings. You say that you would like to be reimbursed for the 
golf you played. The Plan denied your request. The Plan says they are unable to reimburse you for missing 
proof of payment. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan will reimburse you 
for fitness services when you provide valid proof of payment. 
 
The Plan's rules for coverage of gym benefits have not been met because in this case, although you submitted 
receipts for the golf you played, the receipts do not include your name. As a result, you have not submitted 
valid proof of payment that can be used to substantiate that you played golf on these dates. Therefore, we 
decided that the Plan does not have to reimburse you for the golf outings played from January 6, 2020, to June 
2, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the magnetic resonance imaging (MRI) of the brain 
(70553) provided on June 11, 2019. 
 
You asked the Plan to hold you harmless for this service. 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 claim was submitted by the 
provider untimely and is therefore not payable. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The Plans contract provider rendered the MRI imaging service in question. The file does not show that the 
Plan provided notice that this service would not be covered. Under Medicare rules, this means this service is 
considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the 
magnetic resonance imaging (MRI) of the brain (70553) provided on June 11, 2019.  
 
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 pay for the medical services provided on June 24, 2020, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. You say that this claim is related to an initial emergency 
room visit. The Plan denied your request. The Plan says rules for payment have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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. Medical documentation in the case record does not support that the items/services 
provided on June 24, 2020, were related to a prior emergency room visit. 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 medical services provided on June 24, 2020, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia 60mg/ml injections. 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of Zoledronic Acid is required before coverage for Prolia under the Part B benefit 
can be considered. Prolia has been approved under the enrollee's Part D benefit. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drug or 
any reason why the plan preferred drug would be unsafe or ineffective for the enrollee. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia 60mg/ml injections.  
 
Benefits for Prolia 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 the Botox injection provided on June 8, 
2020. 
 
You asked the Plan to waive the coinsurance for the Botox injection. You say that you were approved for 
Botox injections for a year. You say that you were not informed that the coverage was any less than 100% 
coverage. The Plan denied your request. The Plan says the coinsurance applied 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 (including administration) for Medicare part B prescription drugs. 
 
You have been asked to pay $244.40, which is 20% of the allowed amount for the Botox injection. The allowed 
amount is $1,222 (20% x $1,222 = $244.40). The Botox injection 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. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the Botox injection provided on 
June 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 based on the documentation provided, the health plan's denial should be upheld. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care 
needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says care can be provided in the current inpatient hospital. 
 
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 there is no documentation provided necessitating admission to a LTACH. The review 
indicates that the enrollee remains hemodynamically unstable for transfer evidenced by increased vent support, 
pressor support for hypotension, narrow-complex tachycardia on Amiodarone, and overwhelming sepsis. The 
review has determined that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. The requested 
LTACH services medically necessary, reasonable, and appropriate for the diagnosis and condition of the 
enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Humira.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.