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

 
We decided that the Plan does not have to waive the coinsurance for a wearable defibrillator provided from 
March 29, 2022, to May 29, 2022. 
 
You asked the Plan to waive the coinsurance for a wearable defibrillator. You say that you did not know you 
would be charged monthly. The Plan denied your request. The Plan says this cost sharing was charged 
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 for in network/durable medical equipment (DME) and related supplies/.  
 
You have been asked to pay 20% coinsurance for wearable defibrillator. The total amount for one month 
$3080.95. The amount you are being asked to pay per month is $616.19 ($3080.95 x 20% = $616.19). The total 
amount you are being asked to pay is $1848.57 for the three months of service ($616.19 x 3 months= 1,848.57) 
This item/service falls within the in network/durable medical equipment (DME) and related 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 coinsurance for a wearable defibrillator provided from March 
29, 2022, to May 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Synvisc (J7325). 
 
You asked the Plan to pre-approve Synvisc. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for the requested drug have not been 
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 Synvisc. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Orthovisc or Supartz FX before they will approve the requested drug, Synvisc. 
There is no indication that the enrollee has tried and failed the required drugs. Based on the medical records 
provided and the Medicare-approved major drug compendia, there is no indication that the Plan's required 
drugs would likely be less effective and/or likely have adverse effects 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 Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Synvisc (J7325).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 4, 2022 to May 3, 
2022. 
 
You asked the Plan to pay for home health services. You say that an NOA was submitted for the dates of 
services billed. The Plan denied your request. The Plan says an NOA claim was not received. 
 
The Plan must follow Medicare rules. Medicare rules say that HHAs shall no longer submit Requests for 
Anticipated Payment (RAPS -TOB 0322) for any HH period of care with a From date on or after January 1, 
2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pay 
for home health services provided from April 4, 2022 to May 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery provided on June 30, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for surgery. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says If the enrollee is in need of a Medicare covered services and we do not have a network 
provider who can provide that service, the out-of-network provider must contact the plan and request 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 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 surgery provided on June 30, 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) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee came from a nursing facility and he has 
dementia. He needs to regain some strength and skilled nursing would help. The Plan denied your request. The 
Plan says criteria for admission to SNF have not been met. Skilled services can be provided on an intermittent 
outpatient basis, in a long-term care facility, or at the home with home health care services. 
  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs or skilled therapy 
needs. The enrollee appears unable to partake in skilled therapy. Daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of the enrollees condition. The enrollees care 
needs can, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a podiatry office visit provided on July 19, 
2022. 
 
You asked the Plan to waive the copayment for a podiatry office visit. You say that you were unsatisfied with 
your visit. The Plan denied your request. The Plan says this cost sharing was charged 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 in-network podiatry services.  
 
You have been asked to pay a $40 copayment for a podiatry office visit. This item/service falls within the in-
network podiatry 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 podiatry 
office visit provided on July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractor services provided on July 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the chiropractor services. You say that the enrollee is in a dual SNP Plan and the 
services should be covered. The Plan denied your request. The Plan says a referral/authorization was not 
obtained prior to services being rendered. 
 
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 chiropractor services provided on July 1, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing care services provided on April 13, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the nursing care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says a referral/authorization was not obtained prior to services being 
rendered. 
 
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 nursing care services provided on April 13, 2022, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services provided from 
June 26, 2022, to June 30, 2022. 
 
You asked the Plan to waive the copayment for physical therapy services. You say that you are appealing the 
denial of the beneficiary's physical therapy services. The Plan denied your request. The Plan says this cost 
sharing was charged 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 enrollees contract with the Plan clearly says that enrollees 
must pay a $20 copayment for each outpatient rehabilitation service.  
 
 The enrollee has been asked to pay a $20 copayment for each outpatient rehabilitation service. The total 
amount you are being asked to pay is $100 ($20 x 5 visits = $100). This item/service falls within the outpatient 
rehabilitation services benefit category. 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 copayment for 
physical therapy services provided from June 26, 2022, to June 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to be transferred to a 
LTACH where there are beds available, and their medical needs can be met. The Plan denied your request. The 
Plan says the request is not medically necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. Continued care in the short-term acute care hospital 
is appropriate until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation 
facility, a sub-acute rehabilitation facility or 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mental health telehealth services 
provided on June 09, 2022, to July 24, 2022. 
 
You asked the Plan to waive the copayment for the mental health telehealth services. You say that you should 
not have copayments due to the COVID-19 waiver. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $120 
copayment for outpatient mental health care. 
 
You have been asked to pay a $120 copayment for the mental health telehealth services. This item/service falls 
within the outpatient mental health 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. The Plan indicated the COVID-19 waiver ended on May 31, 2022. Per the 
EOC, there is a $40 copayment for mental health services. The file shows 3 visits for a total of $120. Therefore, 
we decided that the Plan does not have to waive the copayment for the mental health telehealth services 
provided on June 09, 2022, to July 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a manual wheelchair provided from December 3, 2021, to 
May 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a manual wheelchair. You say that this should have been covered, and that you 
do not need anything to see an out of network provider. The Plan denied your request. The Plan says there was 
no preauthorization by a primary care provider (this is different than a referral) for an Out-Of-Network 
provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 a manual wheelchair provided from December 3, 
2021, to May 3, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services provided on July 18, 2022. 
 
You asked the Plan to waive the copayment for x-ray services. You say that you feel that you should not owe it. 
The Plan denied your request. The Plan says this cost sharing was charged 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 in-network x-rays provided in an outpatient hospital.  
 
You have been asked to pay a $50 copayment for x-ray services. This item/service falls within the in-network 
x-rays provided in an outpatient hospital 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 x-ray services provided on July 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for laparoscopy on July 21, 2022. 
 
You asked the Plan to waive the coinsurance for laparoscopy. You say that you were told this would be in-
network and your copayment would only be $350. The Plan denied your request. The Plan says this cost 
sharing was charged 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% 
coinsurance for out-of-network inpatient hospital. The provider billed in the amount of $20,333.35 and the 
allowed amount is $4,998.40. $4,998.40 x 50% = $2,499.20. Therefore, results in the total cost sharing amount 
of $2,499.20. 
 
You have been asked to pay a 50% coinsurance for laparoscopy. This item/service 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 coinsurance for laparoscopy on July 21, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare part B prescription drugs 
provided on March 22, 2022. 
 
You asked the Plan to waive the coinsurance for part B prescription drugs. You say that you are disputing the 
amount of $216.12 assessed as your total cost share. The Plan denied your request. The Plan says this cost 
sharing was charged 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 for Medicare-covered part B drugs. The allowed amounts of the drug total $879.14, resulting in a 
total coinsurance amount $216.12, which is less than 20% coinsurance. 
 
You have been asked to pay 20% coinsurance for part B prescription drug. This item/service falls within the 
Medicare-covered part B 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 prescription drugs provided on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a walk-in clinic visit provided on June 5, 
2022. 
 
You asked the Plan to waive the copayment for a walk-in clinic visit. You say that you are asking for 
reconsideration of the cost share. The Plan denied your request. The Plan says this cost sharing was charged 
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 urgently needed services.  
 
You have been asked to pay a $40 copayment for a walk-in clinic visit. This item/service falls within the 
urgently needed 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 walk-in 
clinic visit provided on June 5, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on April 15, 
2022. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that the plan should have paid 
more and you should not have been charged. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $275 
copayment for ambulance services. 
 
You have been asked to pay a $275 copayment for an ambulance ride. This item/service falls within the 
ambulance 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. You are being asked to pay a $266.91 copayment, rather than the full copayment of $275 for 
ambulance services. Therefore, we decided that the Plan does not have to waive the copayment for an 
ambulance ride provided on April 15, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 88360-26 billed for date of service December 9, 2021. 
 
You asked the Plan to pay for code 88360-26. You say that you believe this code was denied in error. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 27, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 88360-26 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 88360-26 billed for date of service December 9, 2021.