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

 
We decided that the Plan does not have to waive the copayments for skilled nursing facility (SNF) care 
provided by a network facility from August 3, 2021, to September 16, 2021. 
 
You asked the Plan to waive the copayments for the SNF care. You say that you should not be responsible for 
the copayments because you received a letter stating you do not have any more copayments. The Plan denied 
your request. The Plan says you have been asked to pay 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 $20 
copayment per day for days 1-20 for a benefit period for each admission and a $120 copayment per day for 
days 21-44 for a benefit period for each admission.  
 You have been asked to pay a $2,400 copayment for the SNF care. The SNF care falls within the Skilled 
nursing facility (SNF) care benefit category. See chart below. 
 
Dates of Service Service SNF Days Copayment Day Count Member Liability 
August 3, 2021, to 
August 16, 2021 
SNF care 1-13 $20 13 $260 
August 19, 2021, to 
August 25, 2021 
SNF care 14-20 $20 7 $140 
August 26, 2021, to 
August 31, 2021 
SNF care 21-26 $100 6 $600 
September 1, 2021, to 
September 16, 2021 
SNF care 27-41 $100 14 $1,400 
Total     $2,400 
 
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 copayments for skilled nursing facility (SNF) care provided by a network 
facility from August 3, 2021, to September 16, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Ocrevus 600mg to be administered intravenously once, every six 
months, for a diagnosis of Multiple Sclerosis. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has been on Ocrevus for the past 
year and a half, and this medication has stabilized their symptoms. The Plan denied your request. The Plan says 
that they require a trial of Glatopa or Gilenya prior to coverage of the Ocrevus. 
 
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 the medication. Our physician reviewer 
found the case file does not contain documentation of trial and failure of Glatopa or Gilenya. Documentation 
by the neurologist supports that the plan's required drugs would potentially be less effective, and/or would 
potentially have adverse effects for the enrollee in this case. Step therapy may only be applied to new 
prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected 
medication. 
 
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 medication have been met. Therefore, we decided that the Plan has to pre-
approve Ocrevus 600mg to be administered intravenously once, every six months, for a diagnosis of Multiple 
Sclerosis.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Omeprazole capsule. 
 
You asked the Plan to pre-approve Omeprazole. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
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 treatment with Omeprazole 
capsule.  
 Benefits for Omeprazole 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) services. 
 
You asked the Plan to pre-approve IRF services. You say that these services are medically necessary for your 
condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 inpatient rehabilitation facility (IRF) 
services have been met. In this case, no medical records have been received documenting your condition. The 
Plan has reached out to your provider for medical records, but no information was recieved. Therefore, we 
decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs and part B drugs 
provided from October 7, 2021, to November 4, 2021. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs and part B drugs. You say that you were 
told you met your maximum out-of-pocket for this year. The Plan denied your request. The Plan says that the 
claim for services on November 4, 2021, applied too much member obligation, the claim was reprocessed, and 
cost sharing was reduced by $30. The Plan also 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 Medicare part B drugs, including chemotherapy drugs. The Plan contract also says 
administration of covered Part B prescription drugs is included in the total cost. Administration may involve 
professional services associated with provision of the covered drug, as well as dispensing, supplying, and/or 
furnishing fees. The Plan contract also says that enrollees must pay a maximum out-of-pocket (MOOP) of 
$5,600. 
 
The record shows that, at the time of processing, your maximum out-of-pocket was met on November 4, 2021. 
You have been asked to pay a total of $1,854.64 for chemotherapy drugs and part B drugs.  
 
 
 
Date of Service Claim 
Number 
Allowed 
Amount 
20% coinsurance 
October 7, 2021 211014064880 $48.20 $9.64 
  $74.67 $14.93 
  $96.40 $19.28 
 
 $374.42 $74.88 
 
 $149.34 $29.87 
 
 $137.67 $27.53 
 
 $1,756.44 $351.29 
  Claim Total: $527.42 
    
October 15, 2021 211021076380 $137.67 $27.53 
 
 $1,756.44 $351.29 
  Claim Total: $387.82 
    
October 28, 2021 211104100970 $74.67 $14.93 
 
 $96.40 $19.28 
 
 $374.42 $74.88 
 
 $149.34 $29.87 
 
 $137.67 $27.53 
 
 $1,756.44 $351.29 
  Claim Total: $517.78 
    
November 4, 2021 211111117816 $374.42 $44.88 (less than 
20%) 
 
 $149.34 $29.87 
 
 $1,756.44 $351.29 
 
 $137.67 $4.58 (less than 
20%) 
  Claim Total: $430.62 
    
Total for all claims:   $1,854.64 
 
 
 
 Chemotherapy drugs and part B drugs 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 chemotherapy drugs and part B drugs provided from 
October 7, 2021, to November 4, 2021.  
 
Your complaint about being given incorrect information about meeting your maximum out-of-pocket is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673). 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that the equipment was 
ordered by the doctor and was used during their surgery. You are not contracted with the facility or the 
ordering physician. The Plan denied your request. The Plan says pneumatic compression device is not covered 
by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. The enrollee used the equipment in the facility during 
and/or after surgery. Payment for this service would have been included under the facility claim. Payment for 
this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that 
the Plan does not have to pay for a pneumatic compression device (E0675) and segmental pneumatic appliance 
(E0673).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a spinal injection provided at a network 
facility on November 24, 2021. 
 
You asked the Plan to waive the copayment for the spinal injection. You say that you feel the Plan should have 
to pay more towards the claim. You say your out-of-pocket cost should be reduced. The Plan denied your 
request. The Plan says you have been asked to pay 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 $450 
copayment at an in-network outpatient hospital.  
 
You have been asked to pay a $450 copayment for the spinal injection. The spinal injection falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 a spinal injection provided at a network facility on 
November 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the 
requested drug is not prescribed for a medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Aranesp. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has a diagnosis of myelofibrosis in the setting of stage III renal insufficiency. The FDA has not stated 
that the requested drug is indicated for the enrollee's condition. The Medicare-approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Aranesp (J0881).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency room visit, and the 
inpatient hospital stay provided by a network facility from June 21, 2021, to June 25, 2021. 
 
You asked the Plan to waive the copayments for the emergency room visit, and the inpatient hospital stay. You 
say that the enrollee should not be responsible for any copayments because he was hospitalized for a direct 
issue from the coronavirus. The Plan denied your request. The Plan says you have been asked to pay 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $90 copayment per visit for emergency care and a $210 copayment per day for days 1-6 per 
admission.  
 
The enrollee has been asked to pay a $90 copayment for the emergency room visit and a $210 copayment per 
day, for the inpatient hospital stay. ($210 x 4 = $840). The emergency room visit falls within the Emergency 
care benefit category. The inpatient hospital stay falls within the Inpatient hospital care benefit category. 
The record shows the admitting diagnosis was a cerebral infarction. 
 
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 copayments for the emergency room visit, and the inpatient 
hospital stay provided by a network facility from June 21, 2021, to June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thyroid hormone, T3 measurement, total (CPT code 84480) 
provided on August 23, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. NCCI PTP edit exists between 84480 and 
84481. This PTP edit has a modifier indicator of 0, which indicates there are no modifiers that are allowed with 
this PTP code pair. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for thyroid hormone, T3 measurement, total (CPT code 84480) provided on August 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that all services that would be provided in the Long-Term Acute 
Care Hospital are being provided in the current acute care setting which is already approved. 
 
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. The patient 
appears to be improving and should only require short-term additional acute care services at the LTACH that 
can safely be administered at the current facility until appropriate for a lower level of care. The patient does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the patient requires that are not already available and covered at the current facility. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insertion of drug-eluting implant (including punctal dilation 
and implant removal when performed) into lacrimal canaliculus (CPT code 0356T) provided on July 8, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the provider did not submit medical documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 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 insertion of drug-eluting implant 
(including punctal dilation and implant removal when performed) into lacrimal canaliculus (Current Procedural 
Terminology (CPT) code 0356T) provided on July 8, 2021. have been met. The appellant did not submit 
medical documentation to corroborate if the services were supported. Therefore, we decided that the Plan does 
not have to pay for insertion of drug-eluting implant (including punctal dilation and implant removal when 
performed) into lacrimal canaliculus (CPT code 0356T) provided on July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 83631, 83520, 82656, 
82274, 87177, 87209) provided on November 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 83631, 
83520, 82656, 82274, 87177, 87209, remain not supported. The place of service on the CMS-1500 form line 
24B must reflect the location of the patient when the specimen was obtained. The submitted claim form 
indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical 
documentation and/or claim history indicates that the specimen was obtained in an Office setting POS 11. Also, 
the laboratory results submitted indicate the specimen was collected on November 4, 2021, and received by the 
lab on November 5, 2021; therefore, the billed code cannot be verified. It is noted multiple attempts were made 
to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for 
the laboratory services (CPT code(s): 83631, 83520, 82656, 82274, 87177, 87209) provided on November 4, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair and raised toilet seat. 
 
You asked the Plan to pre-approve a shower chair and raised toilet seat. You say that you need these items. The 
Plan denied your request. The Plan says this equipment is not covered under your current plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs and raised toilet seats are not 
covered because they are not primarily medical in nature.  
 
While a shower chair or a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers 
coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a shower chair and 
raised toilet seat.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dronabinol capsules. 
 
You asked the Plan to pre-approve Dronabinol capsules. You say that the enrollee has tried and failed over the 
counter, preferred formulary alternatives. You also say that the Dronabinol capsules are warranted so the 
enrollee may regain some weight. The Plan denied your request. The Plan says this drug is not eligible for 
coverage under Part B as prescribed. 
 
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 Dronabinol capsules.  
 
Benefits for Dronabinol capsules may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.