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

We decided that the Plan does not have to waive the copayment for wound debridement provided on February
21, 2020 and March 13, 2020.
You asked the Plan to waive the copayment for wound debridement. You say that copayments are being
applied to bills you never receive. You say that you keep paying the same bill. The Plan denied your request.
The Plan says the copayments 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 $35
copayment for each Medicare-covered podiatry visit.
You have been asked to pay a $35 copayment for each visit for wound debridement. The total amount you owe
is $70 ($35/visit x 2 visits = $70). Wound debridement falls within the "Podiatry services" benefit category.
The records show that the wound debridement was provided by a podiatrist. 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 wound debridement provided on February 21, 2020 and March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and ophthalmic ultrasound
provided on February 3, 2020.
You asked the Plan to waive the copayment for the office visit and ophthalmic ultrasound. You say that you
don't usually have an additional charge. You say that you should only have a $10 copayment. The Plan denied
your request. The Plan says the copayments 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 $10
copayment for outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye,
including treatment for age-related macular degeneration and a $20 copayment for x-rays and ultrasounds.
You have been asked to pay a total of $20 for the office visit and ophthalmic ultrasound.
The office visit falls within the "Vision care" benefit category. The ophthalmic ultrasound falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the office visit and ophthalmic ultrasound provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network
provider.
You asked the Plan to pre-approve the referral. You say that you would prefer to have this provider do the
surgery so you can have the pre-op and post-op appointments closer to home instead of traveling. The Plan
denied your request. The Plan says there are in-networks providers available for these services.
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
a referral to an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
November 20, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration
because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating
room through the length of the procedure. The Plan denied your request. The Plan says payment for this service
is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier
other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the pump assembly and operation have not been met. Specifically, payment for this service is
included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore,
we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
November 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the inpatient stay provided from July 5,
2019 through July 6, 2019.
You asked the Plan to waive the coinsurance for the inpatient stay. You say that 80% of the charges should
have been paid. You say that most hospital expenses were paid for in the past. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay 50% of the Medicare-allowed amount per stay for each out-of-network, Medicare covered inpatient
hospital stay.
The enrollee has been asked to pay $6,638.72, which is 50% of the allowed amount for the inpatient stay. The
allowed amount is $13,277.44 (50% x $13,277.44 = $6,638.72). The inpatient stay falls within the "Inpatient
hospital care" benefit category. The records show that the provider is out-of-network. This means that the
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan
does not have to waive the coinsurance for the inpatient stay provided from July 5, 2019 through July 6, 2019.
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 the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 based on the provided medical records you are receiving necessary services in the
present acute care hospital. Continued care at this level is appropriate until you are stable to transfer to a lower
level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation
facility or home with home health services.
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: 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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 records do not indicate that there are significant, or complex medical/nursing issues
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other
medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is
mostly moderate assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer
duration of therapy can allow for measurable gains to be attained within a predicted period.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lido/Prilocn Cream 2.5-2.5%.
You asked the Plan to pre-approve Lido/Prilocn Cream 2.5-2.5%. You say that the requested medication is
necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D
benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the
criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Lido/Prilocn Cream 2.5-
2.5%.
Benefits for Lido/Prilocn Cream 2.5-2.5% 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 reduce the coinsurance for the Part B injection provided on February
14, 2020.
You asked the Plan to reduce the coinsurance for the Part B injection. You say that you have had this injection
many times and it has doubled in price. You say the increase of price was not explained. The Plan denied your
request. The Plan says you have been charged the correct cost sharing 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 Part B drugs that are administered by a provider.
You have been asked to pay $228.56 which is 20% of the allowed amount for the Part B injection. The allowed
amount is $1,142.78. ($1,142.78 x 20% = $228.56). The Part B 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 reduce the coinsurance for the Part B injection
provided on February 14, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested consultation office visit.
You asked the Plan to pre-approve the consultation office visit. You say that you are not satisfied with the innetwork
provider as you have not been getting better. The Plan denied your request. The Plan says services
with out-of-network providers are not covered unless it is an emergency or urgent 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 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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the
requested consultation office visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 16, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 physician services provided on December 16,
2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from
January 25, 2019 to January 31, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are on a fixed
income and cannot pay this bill. The Plan denied your request. The Plan says you have been charged the correct
cost sharing 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 a $320
copayment for each day for days 1 to 5 for Medicare-covered hospital care and a $0 copayment for additional
Medicare-covered days.
You have been asked to pay a $320 copayment for each day, for days 1 to 5 of the inpatient hospital stay. ($320
x 5 = $1,600). The inpatient hospital stay falls within the "Inpatient hospital care" 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 inpatient hospital stay provided from January 25, 2019 to January
31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided.
You asked the Plan to pre-approve the physician's services to be provided. You say that this doctor is very knowledgeable in alternative medicine offered at the Center for Integrative Medicine. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on August 2, 2019.
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says routine vision services must be received from approved providers.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when received from approved providers. We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion for podiatry services to be provided by an out of network provider.
You asked the Plan to pre-approve a second opinion for podiatry services. You say that you are appealing because your husband has had bad experiences with in-network podiatry specialists, complications after surgery stating they need to amputate your husband's leg. You are requesting this physician because he states that it is not necessary to amputate your husband's leg and he has a much less invasive surgery that can be performed. The Plan denied your request. The Plan says members of the Plan must use the network providers to receive covered medical care and services. There are some exceptions, such as urgencies, emergencies out of area dialysis, and when you need covered services that are not available within the network.
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 pre-approved care.
The Plan has determined that a second opinion in your husband's medical condition can be provided by a podiatrist within the Medical Centers Health Plans network. Your husband's primary doctor's office has been asked to consider referring him to a podiatrist within the network for a second opinion. 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 a second opinion for podiatry services to be provided by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for polycarbonate lenses and anti-reflective coating provided on
August 21, 2019.
You asked the Plan to pay for polycarbonate lenses and the anti-reflective coating. The Plan denied your
request. The Plan says lenses with polycarbonate and anti-reflective coating are enhancements and outside your
benefit limitation.
Medicare generally does not cover routine eyewear services. Medicare rules say that that anti-reflective coating
(V2750) are covered only when they are medically necessary for the individual beneficiary and the medical
necessity is documented by the treating physician. When these features are provided as a beneficiary preference
item and are billed with an EY modifier they will be denied as not reasonable and necessary. Medicare rules say that the use of polycarbonate or similar material (V2784) for indications such as light weight or thinness
will be denied as a non-covered deluxe feature.
We looked at the file, Medicare's rules and the Plan's rules. Medicare says that the use of polycarbonate or
similar material for indications such as light weight or thinness will be denied as a non-covered deluxe feature.
Medicare says that Medicare only covers anti-reflective coating when documented by the treating physician as
medically necessary. The file does not contain documentation from the treating physician to substantiate
Medicare's coverage criteria for the anti-reflective coating. The Plan says that lenses with polycarbonate and
anti-reflective coating are enhancements and outside your benefit limitation. Therefore, we decided that the
Plan does not have to pay for polycarbonate lenses and anti-reflective coating provided on August 21, 2019.