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

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on December 
27, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you went for a drive up 
COVID-19 test and was informed that you were not going to be charged for the test. 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 a $50 
copayment for an urgent care visit.  
 
The medical record shows that you had an urgent care visit on December 27, 2021. You have been asked to pay 
a $50 copayment for an urgent care visit. An urgent care visit 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 an urgent care visit provided on 
December 27, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after April 25, 
2022. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says that the enrollee no 
longer meets the health condition to stay in a SNF. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before April 25, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pre-approve continued skilled nursing facility (SNF) services after April 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ultrasound of the extremity veins 
provided on October 13, 2021. 
 
You asked the Plan to reduce the copayment for an ultrasound. You say that you have an ultrasound every year 
but for the last two years you have been charged more than the $45 copayment your used to paying. 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 a $175 
copayment for in-network radiological diagnostic services, including ultrasounds.  
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$175 copayment for an ultrasound. An ultrasound 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 an 
ultrasound of the extremity veins provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root canals (D3310 x 3) provided on December 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary and meet the 
standard of care necessary to help with pain and infection. You say that you felt much better after your root 
canal treatment. You also say that the services should be covered. The Plan denied your request. The Plan says 
there is a 50% coinsurance for root canals. The Plan says there is an allowance of $1,000. The Plan also says 
that after the annual maximum is exhausted, any remaining charges are your responsibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage and root canals are listed as covered, 
there is a 50% coinsurance that applies. $753 x 50% = $376.50. This is a contractual obligation you agreed to 
when you enrolled in the Plans dental coverage. Additionally, the record shows that the $1,000 annual 
maximum has been met with the processing of this claim. 
 
Date of Service Plan Paid 
5/11/2021 $273 
11/29/2021 $47 
12/6/2021 $98 
12/13/2021 $582 
TOTAL: $1,000 
 
Therefore, we decided that the Plan does not have to pay for the root canals (D3310 x 3) provided on December 
13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Renflexis. 
 
You asked the Plan to pre-approve Renflexis. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy criteria. 
 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 Renflexis. Our reviewer says that 
Reflexis is not medically reasonable and necessary in this case. Our physician reviewer found that there is no 
indication that the enrollee has tried and failed the required drug(s). Based on the medical records provided, 
there is no indication that the plan's required drug(s) 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 Renflexis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Renflexis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are in a lot of pain and would prefer shoe 
inserts before choosing surgery. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve a complete maxillary denture. You say that the enrollee needs the denture 
but cannot afford to pay for it. The Plan denied your request. The Plan says this service is not covered under the 
enrollee's benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete maxillary denture (D5110).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha. 
 
You asked the Plan to pre-approve Repatha. 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 drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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. The enrollee is medically stable and does not need physical medicine and rehabilitation physician supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. There are no acute rehab nursing needs identified or documented in the record. At the 
current functional level, the enrollee does 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. The enrollee's rehab needs can be 
met safely and provided at a lower intensity and alternate setting. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015), frames 
(V2020), and two spherocylinders (V2103 x2) provided on July 21, 2021 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the determination of refractive state, frames, and spherocylinders. The Plan 
denied your request. The Plan says the enrollee was assessed a lesser cost-share for the eye exam since the 
Medicare-allowed amount is $19.27, and the cost-share is only applied up to the allowed amount. The Plan also 
says that these services were rendered by an OON provider and the enrollee's plan only covers eyewear when it 
is purchased from a Plan Vision network provider. 
 
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 these services when eyewear is provided by an in-network provider. 
 
We looked at the file and the Plan's rules. You are responsible for a $45 copayment for each Medicare-covered 
eye exam, but you are being charged less because the allowed amount was less than $45. The frames and 
spherocylinders are not covered because they were rendered by an OON provider. Based on this information, 
we decided that the Plan's rules for coverage of the determination of refractive state, frames, and 
spherocylinders have not been met. Therefore, we decided that the Plan does not have to pay for the 
determination of refractive state (92015), frames (V2020), and two spherocylinders (V2103 x2) provided on 
July 21, 2021 by an out-of-network (OON) provider.
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 service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
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 the member's medical conditions are stable and there are no complex nursing or rehabilitation needs. While the member may have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program.  
 
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. Specifically, medically necessary services can be 
obtained in a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we 
decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and 
services.
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. You say that the enrollee needs pneumonia therapy services. 
The Plan denied your request. The Plan says that the enrollee can get the care he needs in another setting. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visit on January 20, 2022. 
 
You asked the Plan to waive the copayment for telehealth visit. You say that you live on a limited income, and 
this is a huge financial burden. The Plan denied your request. The Plan says coinsurance is correct. 
 
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 30% 
coinsurance for each Medicare-covered out-of-network visit.  
 
You have been asked to pay $28.95, which is 30% of the allowed amount for telehealth visit. The allowed 
amount is $96.51 (30% x $96.51 = $28.95). Telehealth visits 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. 
Therefore, we decided that the Plan does not have to waive the copayment for telehealth visit on January 20, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a positron emission tomography (PET) 
scan provided on July 6, 2021. 
 
You asked the Plan to waive the copayment for the PET scan. You say that you do not know what the bill was 
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 a $150 
copayment for each advanced imaging service, such as PET scans.  
 
The file shows that the Plan reprocessed the claim and removed the $967.92 coinsurance for the contrast agent. 
Therefore, you have only been asked to pay a $150 copayment for the PET scan. The PET scan 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 waive the copayment for a positron emission tomography (PET) scan provided on 
July 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97110) provided on November 17, 
2021. 
 You asked the Plan to pay for physical therapy. You say that these services were medically necessary and were 
billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical 
Therapist. There is no indication that the Nurse Practitioner was present on site while the therapy services were 
being rendered. The incident-to requirements have not been met in this case. Based on this information, we 
decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the 
Plan does not have to pay for physical therapy services (97110) provided on November 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron Tabs. 
 
You asked the Plan to pre-approve Ondansetron Tabs. You did not provide a specific argument for coverage in 
your appeal request. The Plan denied your request. The Plan says this drug is not covered under the patient's 
medical benefits. 
 
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 Ondansetron Tabs.  
 
 
  
Benefits for Ondansetron Tabs 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Prolia (J0897). 
 
You asked the Plan to pre-approve the Prolia. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the member has not met the step therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Prolia. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the patient has not tried and failed the 
required step therapy drug and there is no documentation indicating the required drugs would likely be less 
effective 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 the Prolia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Prolia (J0897).
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 enrollee cannot get the therapy she needs at a 
skilled nursing facility (SNF) due to the staff they have there. She needs more therapy than the SNF can offer. 
The enrollee would be a fall risk if she returned home as she has no one to help her. The Plan denied your 
request. The Plan says RF care is not medically necessary. The enrollee is currently in a SNF but does not meet 
criteria for IRF care. 
 
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 the enrollee is medically stable with no acute problems and has no medical 
complexity and does not need physician close supervision 3 times per week (at a minimum) for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. No rehab nursing needs 
identified or documented in the record. 
 
At the functional level as described above, the enrollee does not need 3 hours a day five days a week of IRF 
therapies with interdisciplinary management. After a month of daily therapies in the SNF, her progress is very 
slow. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute 
hospital inpatient rehab stay with an interdisciplinary approach to rehabilitation care. While the enrollee may 
benefit from therapy, her rehab needs can be safely addressed at a low intensity alternate 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 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.