Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services 
provided from September 1, 2021, to September 30, 2021. 
 
You asked the Plan to waive the copayment for the SNF services. You say that the enrollee should not be 
charged for services rendered due to a surgical site infection. The Plan denied your request. The Plan says the 
enrollee has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 per day for days 1-20, $135 per day for days 21-45, and $0 per day for days 46-100 for each 
benefit period.  
 The file shows that the enrollee was admitted to the skilled nursing facility from August 3, 2021, to August 18, 
2021, and again from September 1, 2021, to September 30, 2021, for a total of 46 days. The enrollee has been 
asked to pay $135 per day for days 21-45 of SNF services. The enrollees total responsibility would have been 
$3,375; however, she had met her maximum out-of-pocket (MOOP) expenses for the year during this stay. 
Therefore, the enrollee has only been asked to pay $1,485, which then met the maximum. The SNF services 
fall within the Skilled Nursing Facility (SNF) Care 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 skilled nursing facility (SNF) services provided from September 1, 2021, to 
September 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone. 
 
You asked the Plan to pre-approve Prednisone. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
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. The record indicates that Prednisone is not being prescribed for immunosuppressive therapy. 
Therefore, we decided that the Plan does not have to pre-approve Prednisone.  
 Benefits for Prednisone 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 pay for the periodic comprehensive exam (99396) provided 
September 20, 2021. 
 
You asked the Plan to pay for the periodic exam. You say that you had a pap smear and thought it was a 
covered benefit. The Plan denied your request. The Plan says this claim line is being disallowed because the 
services are not covered by Medicare. 
 
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, the CPT Code Manual definition of code 99396 is periodic comprehensive preventive medicine 
reevaluation and management of an individual including an age and gender appropriate history, examination, 
counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic 
procedures, established patient; 40-64 years. 
 
We find that CPT code 99396 is not supported in the medical record. Specifically, the billed code 99396, is not 
covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the periodic 
exam have not been met. Therefore, we decided that the Plan does not have to pay for the periodic 
comprehensive exam (99396) provided September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee September 
10, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  
The 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 out of network services provided to the enrollee 
September 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve acupuncture services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says there are multiple in-network providers available to provide these 
medical services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture services to be provided 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 an ultrasound provided on September 20, 
2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were told this service would be 
paid in full. The Plan denied your request. The Plan says the proper copayment was applied. 
 
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 $30 
copayment for each X-ray service.  
 
  You have been asked to pay a $30 copayment for an ultrasound. An ultrasound falls within Outpatient 
diagnostic tests and therapeutic services and Supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an ultrasound provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutritional therapy provided on September 28, 2021. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that these services should be covered 
by the Plan. The Plan denied your request. The Plan says that you were being treatment for anemia. The Plan 
says you did not meet the coverage criteria for this service and the provider submitted an agreement you signed 
indicating you were told this was not covered by insurance. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes. The records do not show that you suffer from renal disease or 
diabetes. Therefore, we decided that the Plan does not have to pay for medical nutritional therapy provided on 
September 28, 2021.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan does have to waive the coinsurance for external infusion pump supplies for November 
9, 2020. We also decided that Plan does not have to waive the coinsurance for external infusion pump supplies 
for May 10, 2021. 
 You asked the Plan to waive the coinsurance for external infusion pump supplies. You say that you were billed 
for diabetic supplies that are supposed to be free when ordered from the Plans pharmacy. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
We decided that the Plan does have to waive the coinsurance for external infusion pump supplies for 
November 9, 2020. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. There are no records showing billed charges or cost sharing amounts for 
November 9, 2020. Additionally, the Plan has not provided the 2020 Evidence of Coverage. We are unable to 
determine what the correct cost sharing amount should be. Therefore, we decided that the Plan does have to 
waive the coinsurance for external infusion pump supplies for November 9, 2020. 
 
We also decided that Plan does not have to waive the coinsurance for external infusion pump supplies for 
May 10, 2021. 
 
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 durable medical equipment and supplies.  
 
The records show the supplies you received are not considered monitoring supplies. They are infusion pump 
supplies. You have been asked to pay $12.08, which is 20% of the allowed amount for external infusion pump 
supplies ($60.40 allowed amount x 20% coinsurance = $12.08). External infusion pump supplies fall within the 
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 external infusion pump supplies provided on and May 10, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for eye surgeries provided on October 21, 
2021, and November 11, 2021. 
 
You asked the Plan to waive the copayments for the eye surgeries. You say that you were told these services 
would be paid in full. The Plan denied your request. The Plan says the proper copayments were applied for the 
services. 
 
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 hospital visits. The total copayment amount for both surgeries was $550 ($275 
copayment amount + $275 copayment amount). 
 
  You have been asked to pay a $550 copayment for the eye surgeries. The eye surgeries 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 copayments for eye surgeries provided on 
October 21, 2021, and November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse you for over the counter items purchased on July 2, 2021.
You asked the Plan to reimburse you for the over the counter items. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the Flex Benefit allows members to be reimbursed for purchases or services that are related to health care, and that members would not normally receive through other Medicare Advantage plans, government funding or programs.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not forwarded evidence to support that these benefits may not be reimbursed if they are purchased using food stamps. There is no indication in the Evidence of Coverage or Flex Summary stating that purchasing these items using food stamps would bar the member from reimbursement. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to reimburse you for over the counter items purchased on July 2, 2021.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you need therapy to transition back home. The Plan
denied your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states
your records show that you are neurologically stable and require routine skilled therapy that can safely be
received at a different setting, for example, home with home health, in residential care, or home with close
follow-up with your doctor.
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 daily
skilled services are not necessary. Our physician reviewer found you have stabilized medically and are ready
for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily
basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although
further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent
skilled services can be provided at a lower level of care than a SNF. You do not have any parental medication;
complex wound care or nutrition given via a feeding tube. You are medically stable without any acute
exacerbations of chronic medical problems. Your physical function is at or near their baseline and you can
receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not
medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you suffered a mini stroke and the test revealed you 
need a stint in your carotid artery. You state your provider, and the rest of your care team believe that skilled 
nursing care can get you back your prior baseline. The Plan denied your request. The Plan says the stay is not 
medically necessary based on SNF criteria. The Plan states your rehabilitation and medical needs can be met 
with part-time skilled services in a lower level of care, such as home with supervision and home health 
services. The Plan states home health services will need to be approved by your health plan. The Plan states your rehabilitation needs can safely be received at a different setting, for example, home with home health, in 
residential care, or home with close follow-up with your doctor. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do 
not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear to 
be functioning at/near your baseline. Daily skilled services are not required to establish a maintenance program 
or to prevent deterioration of your condition. Your care needs, custodial and intermittent, can, as a practical 
matter, can 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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on October 15, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that when you visited this provider, you had blurred 
vision and were concerned that you were experiencing a potential onset of diabetic retinopathy.  These services were necessary. The Plan denied your request. The Plan says you had a previous eye refraction 
provided on February 22, 2021, which was covered by the Plan at that time. This service may only be covered 
once per year. In addition, the exam in this case was provided for medical purposes and is covered by 
Medicare. Medicare does not cover eye refractions for medical purposes, and the Plan's supplemental benefit 
only covers eye refractions in conjunction with a routine (non-medical) eye exam. 
 
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 one eye refraction per calendar year when it is performed as part of a routine eye 
exam. 
 
We looked at the file and the Plan's rules. The eye refraction in this case was performed as part of a medical 
(non-routine) eye exam because you were experiencing symptoms which caused concern. Eye refractions are 
not covered by Medicare, and they are only covered once per year with a routine eye exam under your 
supplemental benefit. Based on this information, we decided that the Plan's rules for coverage of the eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction 
(92015) provided on October 15, 2021.
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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 that the complexity of the members nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The member continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement however, the documentation doesnt 
support that she would meet criteria for admission to an acute inpatient rehabilitation facility. There is no 
indication that the member would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her 
functional status. The member can receive further services 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 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.