Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation provided April 26, 
2022, to May 12, 2022. 
 
You asked the Plan to waive the copayment for inpatient rehabilitation. You say that you assumed all of your 
expenses would be covered. 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 $298 
copayment per day, for days 1 to 5; $0 copayment per day for days 6 to 90 for in-network inpatient 
rehabilitation. for inpatient hospital care.  
 
 
 
 You have been asked to pay $298 per day for in-network inpatient rehabilitation. The total you owe is $1,490 
($298/day x 5 days = $1,490). 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 copayment for inpatient rehabilitation provided 
April 26, 2022, to May 12, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara. 
 
You asked the Plan to pre-approve Stelara. You say that the enrollee is in need of medication. The Plan denied 
your request. The Plan says the enrollee has not tried one of the Plan's preferred drugs. 
 
 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 Stelara. Our physician reviewer found 
that the enrollee has ulcerative colitis. The Plan requires a trial of Avsola, Entyvio, or Remicade before they 
will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is 
no documentation provided indicating that the Plans required drugs would likely be less effective 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 Stelara have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stelara.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider. 
 
You asked the Plan to pre-approve an office visit. The Plan denied your request. The Plan says there are 
specialist options available to include behavioral health specialists in addition to providers through a digital 
resource from the Plan that are in-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 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 
an office visit to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a magnetic resonance imaging (MRI) 
provided on June 16, 2022. 
 
You asked the Plan to reduce the copayment for a magnetic resonance imaging (MRI). You say that this is 
catagorized incorrectly, you were not in a hospital. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $275 copayment for a magnetic resonance imaging (MRI). This item/service 
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 reduce the copayment for a magnetic resonance imaging (MRI) provided on June 16, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for inpatient hospital care provided from February 24, 
2022, to February 25, 2022. 
 
You asked the Plan to reduce the copayment for inpatient care. You say that your copayment should only be 
$150. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $150 copayment per day for days 1 to 8 for inpatient 
hospital care. This hospital stay was billed as an elective inpatient admission, and the Plan also agrees that this 
stay was provided on an inpatient basis. However, the Plan applied an outpatient hospital copayment to each 
separate day rather than applying an inpatient per diem copayment to the stay, meaning that the Plan 
inappropriately applied a copayment to the hospital discharge day. This inpatient stay lasted 1 day, resulting in 
a copayment amount of $150. 
 
The Plan says you must pay $293.43 copayment amount for inpatient care. Based on the Plan contract, 
however, you cannot be asked to pay more than $150 copayment for inpatient care. Therefore, we decided that 
the Plan has to reduce the copayment for inpatient hospital care provided from February 24, 2022, to February 
25, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you need to be able to get outside. You also 
say you need the power scooter and the one he has is for inside use only. The Plan denied your request. The 
Plan says the DME benefits require use within the home for coverage eligibility. In addition, the Plan approved 
authorization for a replacement power wheelchair that can be used inside of the home. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The rules also state that for equipment to be covered, it must be appropriate and 
needed for use inside the home. 
 
 
 
 The file shows that you have a power wheelchair which serves the same purpose as a power scooter. The item 
at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor 
the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-
approve a power scooter (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on June 9, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
  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 office visit provided on June 9, 2022, by an out-
of-network (OON) provider.
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 requires transfer to an 
LTACH as his condition has stabilized, and he will require a multi-disciplinary approach for an extended 
period of time. You say that the enrollee requires the daily treatment that only an LTACH can provide. The 
Plan denied your request. The Plan says the LTACH services requested do not meet the requirements for 
approval. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting. 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endocrinology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee would like to see the provider. The 
Plan denied your request. The Plan says the care can be provided by a network provider. 
 
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 OON services. Therefore, we decided that the Plan does not have to pre-approve 
endocrinology services to be provided by an out-of-network (OON) provider.
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 these services. You say that you perform blood checks twice per day and 
there is no blood in your fingers. The Plan denied your request. The Plan says the criteria for coverage are not 
met. 
 
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 you do not treat with insulin three or more times per day or use an insulin pump. Based on this information, we decided that Medicare rules for 
coverage of these services 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe lens feature (V2702), photochromatic tint 
(V2744), anti-reflective coating (V2750), progressive lens (V2781), high-index lens (V2783), and vision 
supply, accessory and/or service component (V2797) provided on March 29, 2022. 
 
You asked the Plan to pay for the deluxe lens feature, photochromatic tint, anti-reflective coating, progressive 
lens, high-index lens, and vision supply, accessory and/or service component. You say that you paid $235.80 
when you ordered the glasses on March 29, 2022. You also say that you received an additional bill for $107.00, 
but no one can explain why you are being charged this additional amount. The Plan denied your request. The 
Plan says the denial of the vision services/items is correct. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers single vision, lined bifocal, lined trifocal, lenticular, and Tier I (standard) progressive 
lenses. 
 
We looked at the file and the Plan's rules. The record shows that you received upgraded lenses and an 
uncovered vision service. Based on this information, we decided that the Plan's rules for coverage of the deluxe 
lens feature, photochromatic tint, anti-reflective coating, progressive lens, high-index lens, and vision supply, 
accessory and/or service component have not been met. Therefore, we decided that the Plan does not have to 
pay for the deluxe lens feature (V2702), photochromatic tint (V2744), anti-reflective coating (V2750), 
progressive lens (V2781), high-index lens (V2783), and vision supply, accessory and/or service component 
(V2797) provided on March 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88333 billed for date of service January 7, 
2022. 
 
You asked the Plan to pay for procedure code 88333. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 88333 is bundled into 
payment for code 88331. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 88333 
is a column II code to column I code 88331. 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 procedure code 88333 billed for date of service January 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Emgality. 
 
You asked the Plan to pre-approve Emgality. You say that the enrollee has had intolerances or 
contraindications to other prophylactic agents. The Plan denied your request. The Plan says this drug is not 
eligible for coverage under the Part B benefit. 
 
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 Emgality.  
 
 Benefits for Emgality 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not have an approved condition for this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has osteoarthritis of the right knee. She takes Tylenol and Codeine as well as 
Tizanidine. There is no pathology of the SI joint identified. Therefore, the request is not medically reasonable 
or necessary. 
 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac joint injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to apply the in-network cost share for inpatient hospital care from 
December 11, 2021, to December 23, 2021. 
 
You asked the Plan to apply the in-network cost share for inpatient hospital care. You say that you were told 
this is an in-network hospital. 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 $495 
copayment per day for days 1 to 27 for out-of-network inpatient hospital care for inpatient hospital care.  
 
You have been asked to pay $5,940 for out-of-network inpatient hospital care for inpatient hospital care 
(495/day x 12 days = $5,940). 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 apply the in-network cost share for inpatient hospital care 
from December 11, 2021, to December 23, 2021.  
 
Your complaint about being given incorrect information about the network status of the hospital 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: 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 skilled nursing facility in your area 
does not have sufficient oxygen. You say that you will be at risk of oxygen deprivation and need to return to 
the hospital. The Plan denied your request. The Plan says the LTACH is not medically necessary, and your 
needs can be provided in the current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are more stable and improving and should only require short-term additional 
acute care services that can be safely administered at the current facility until more stable appropriate for a 
lower level of care. You do not require services at the LTACH that are not already available at the current 
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 long term acute care hospital (LTACH) services.
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 would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient care at the current hospital and can remain there until ready for discharge to a 
lower level of 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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.