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

 
We decided that the Plan does not have to waive the copayment for the PT visit provided on January 12, 2022. 
 
You asked the Plan to waive the copayment for the PT visit. You say that you were told you would have a $15 
copayment, not $40. The Plan denied your request. The Plan says the copayment was 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 when 
out-of-network, a $40 copayment at an outpatient hospital.  
 
You have been asked to pay $40 for the PT visit. PT visits fall 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 a physical therapy (PT) visit 
provided on January 12, 2022.
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 enrollee will fail at a lower level of 
care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with dysarthria, left hemiparesis related 
to stroke/thrombus, complicated by acute respiratory failure. The enrollee appears to be more stable and 
improving. He should only require short-term additional acute care services that can be safely administered at 
the current facility. There are no services at the LTACH that he requires that are not already available and 
covered at the current facility. Transfer to LTACH is not supported and will be considered not medically 
necessary at this time as it would not be clinically advantageous. 
 
 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Evaluation and Management services
provided on December 6, 2021.
You asked the Plan to waive the copayment for Evaluation and Management services. You say that you have a
travel benefit card and that you saw your primary care provider. The Plan denied your request. The Plan says
Although the doctor is a primary care provider the bill was submitted under an ancillary provider and does not have the classification of Primary Care Physician. The claim was processed 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 Evaluation and Management services.
You have been asked to pay a $50 copayment for Evaluation and Management services. Evaluation and
Management services falls within the Physician/Practitioner services, including 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. Therefore, we
decided that the Plan does not have to waive the copayment for Evaluation and Management services provided
on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sprint peripheral nerve stimulation (PNS). 
 
You asked the Plan to pre-approve Sprint PNS. You say that this is a temporary lead placement (only left in for 
2 months), so no trialing is needed with this. Sprint system is a newer system. Please review your request for an 
appeal on this procedure. The Plan denied your request. The Plan says the Sprint PNS device does not fit the 
Medicare definition of an implanted peripheral nerve stimulator. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Sprint PNS have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Sprint peripheral nerve stimulation (PNS).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital observation stay
provided from October 12, 2021, to October 13, 2021.
You asked the Plan to waive the copayment for outpatient hospital observation stay. You say that you thought
you were admitted into the hospital and you were unaware you were just in observation. The Plan denied your
request. The Plan says the copayment was 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 $350
copayment per stay for outpatient observation stays for the Plan.
You have been asked to pay $350 for the outpatient hospital observation stay. Outpatient hospital observation
stays fall within the "Outpatient hospital observation" 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 outpatient hospital observation stay provided from October 12, 2021, to October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on January 12,
2022.
You asked the Plan to waive the copayment for an eye exam. You say that these benefits are deceiving and cost
you money you don't have. The Plan denied your request. The Plan says the copayment was 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 $40
copayment for each Medicare-covered eye exam.
You have been asked to pay $40 for an eye exam. Eye exams fall within the "Vision 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 eye exam provided on January 12, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a central motor evoked potential study provided to the
enrollee on August 30, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says you are not a recognized facility or a legally-qualified physician.
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are
enrolled in the Medicare program.
You are not eligible to bill Medicare. The Plan did not pre-approve the services. We found no exception that
would require the Plan to pay for these items/services. Based on this information, we decided that Medicare
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay
for a central motor evoked potential study provided to the enrollee on August 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 testing provided on November 25, 2021.
You asked the Plan to pay for the COVID-19 testing. You say that you would like reconsideration because you
were required to take a COVID-19 test before traveling back to the United States. The Plan denied your
request. The Plan says you were not able to provide the results of this testing or an itemized bill.
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if
regular Medicare would pay for it.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the COVID-19 testing have not been met. Specifically, the documentation does not support that
this testing was urgent, emergent or ordered by your physician. Additionally, the record does not include an
itemized bill for reimbursement. Therefore, we decided that the Plan does not have to pay for the COVID-19
testing provided on November 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. You say that you would like to appeal this 
decision because the transportation is necessary for dialysis treatments. The Plan denied your request. The Plan 
says you have exhausted the established benefit of 24 one-way trips. 
 
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 one-way 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 non-emergency taxi transportation (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life Alert system for the enrollee. 
 
You asked the Plan to pre-approve a Life Alert system. You say that this is necessary for the enrollee. The Plan 
denied your request. The Plan says that this is a convenience item and not covered. 
 
The Plan must follow Medicare rules. The rules say that telephone alert systems are excluded from coverage as 
these are emergency communications systems and do not serve a diagnostic or therapeutic purpose. 
 
Although this device may be appropriate, it is not covered by Medicare. Therefore, we decided that the Plan 
does not have to pre-approve a Life Alert system for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve testosterone. 
 
You asked the Plan to pre-approve testosterone. The Plan denied your request. The Plan says this drug is not 
covered under the enrollee's Part B plan. 
 
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 testosterone.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that these are medically necessary. The Plan 
denied your request. The Plan says that there is no indication that you are using insulin three times each day. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and supplies.
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 this level of care is beyond what can be 
expected at a skilled nursing facility. The Plan denied your request. The Plan says the enrollee's needs are being 
met in the current acute setting. 
 
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 physician 
reviewer found the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where she 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 health plan has 
approved ongoing care in the current acute care facility. The requested LTACH services are not 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 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 you are medically stable and do not need PM&R physician supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. At the current functional mobility level, you do not need intensive therapies, consisting of at least 3 
hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. Your rehab needs 
can be met safely and provided at a lower intensity and alternate setting such as in a skilled nursing facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cardiology Echocardiology services provided on February 8, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Cardiology Echocardiology services. You say that you would like to appeal the 
denial of the claim. The Plan denied your request. The Plan says the service is not covered for out of network 
providers. 
 
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 had network providers 
available who could have provided 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 Cardiology Echocardiology services provided on 
February 8, 2022 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you have used 
100 days in this benefit period. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from November 12, 2021, to 
May 23, 2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested provider. You say that 
IPL and VBEAM treatment is not available in-network. The Plan denied your request. The Plan says medically 
necessary services are available within the member's network and there are no extenuating circumstances 
making it medically necessary to obtain the service out-of-network. The denial is in accordance with Medicare 
policy and Plan benefits as explained in the member's Evidence of Coverage. 
 
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 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a hyaluronan injection and drug 
administration provided on December 30, 2021. 
 
You asked the Plan to waive the cost share for an injection and drug administration. You say that you do not 
know what these charges are for. 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 and drug administration. The contract says the administration of that drug, you 
will pay the cost-sharing that applies to primary care provider services, specialist services, or 
outpatient hospital services. The Plan contract also says that enrollee must pay a $20 copayment for services 
obtained from a specialist. 
 
You have been asked to pay $206.88, which is 20% coinsurance of the allowed amount for an injection 
($1,034.40 allowed amount x 20% coinsurance = $206.88). An injection falls within the Medicare Part B 
Prescription Drugs benefit category.  
 
You have been asked to pay a $20 copayment for the administration of a drug by a specialist. The 
administration of a drug by a specialist falls within the Physician/Practitioner Services, Including Doctors 
Office Visits benefit category. You have been asked to pay a total of $226.88 ($206.88 coinsurance + $20 
copayment = $226.88). 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 a hyaluronan injection and drug 
administration provided on December 30, 2021.