Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on February 11, 2022. 
 
You asked the Plan to pay for home health services. You say that there are orders for the home visit which 
specify the medical treatment and the type of home health discipline to be furnished with frequency. The Plan 
denied your request. The Plan says the submitted records do not contain documentation to support the enrollee 
is eligible for the services requested. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
The record did not include a provider certified plan of care showing that you need home health care services.  
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 the home health services provided on 
February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for automatic external defibrillator provided 
on July 21, 2022. 
 
You asked the Plan to waive the coinsurance for automatic external defibrillator. You say that you are 
disputing the share cost. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for automatic external defibrillator. This item/service falls within 
the durable medical equipment 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 automatic external defibrillator provided on July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for hearing aids (V5260) provided on August 30, 2022. 
 
You asked the Plan to pay more for hearing aids. You say that you did your due diligence and were given the 
incorrect information by the hired hearing aids claims processing company. You also say that it is not your 
fault you were given erroneous information. The Plan denied your request. The Plan says you went to an out-
of-network provider. The Plan also says that the out-of-network liability for hearing aids is 25% coinsurance, 
then any amount over $1,000 every 3 years. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan rules say 
that for hearing aids purchased out-of-network, you pay 25% coinsurance, then any amount over $1,000 every 
three years. The record shows these hearing aids were purchased from an  
out-of-network provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay more for 
hearing aids (V5260) provided on August 30, 2022.
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 do not want to go home by yourself as you 
cannot walk or do anything without assistance. The Plan denied your request. The Plan says a SNF admission 
is not medically necessary. 
 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 that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay the coinsurance for Denosumab injection provided on August 
19, 2022. 
 
You asked the Plan to pay the coinsurance for injection. You say that you believe you are being charged for 
services that you should not be charged for. 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 chemotherapy drugs and $35 copayment for Provider and Professional services specialist 
office. 
 
  You have been asked to pay a total of $306.60 for Denosumab injection.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
August 19, 2022 Drug Denosumab $1,358 20% $271.60 
August 19, 2022 Injection service $61.23 $35 $35 
Total:    $306.60 
 
Denosumab injection falls within the Medicare Part B prescription drugs and 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 pay the coinsurance for 
Denosumab injection provided on August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the outpatient services provided from 
January 20, 2022, to September 16, 2022. 
 
You asked the Plan to waive the cost share for the outpatient services. You say that you feel as though you are 
being charged for facility use and paying a copayment as well. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. The Plan says that the facility is also allowed to submit claims for payment. 
 
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 there is a $400 deductible which applies to Outpatient hospital services.  
 
The outpatient clinic visits you asked the Plan to waive the cost share for fall within the Outpatient hospital 
services benefit category. 
 
Your contract also says that enrollees must pay a $40 copayment for outpatient lab services. The outpatient lab 
services fall within the Outpatient diagnostic tests benefit category. 
 The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 deductible which 
applies to Outpatient hospital services and a $40 copayment that applies to outpatient lab services. This cost 
sharing is a contractual obligation that had not been met at the time the outpatient services were received from 
January 20, 2022, to September 16, 2022. Therefore, we decided that the Plan does not have to waive the cost 
share for the outpatient services provided from January 20, 2022, to September 16, 2022.  
 
Your complaint about being charged for facility use and a copayment as well 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve chiropractic manipulative treatments (98940). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that you have exhausted the allowable benefit for 
these services. 
 
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 Plans contract states that supplemental coverage is provided 
for a complimentary medicine benefit that includes routine chiropractic services. The maximum annual benefit 
is $2,000 for these services. The Plan has stated that you have exhausted the allowable benefit for these 
services this calendar year. However, the Plan has not provided substantive evidence that demonstrates that you 
have previously received services under this benefit or that payment has been issued by the Plan for this benefit 
in the amount of $2,000. The Plan has not substantiated their denial; therefore, we must find in your favor. 
Therefore, we decided that the Plan has to pre-approve chiropractic manipulative treatments (98940).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on July 20, 2022. 
 
You asked the Plan to waive the copayment for lab services. You say that this was part of your annual, and 
should not have a copayment. 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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for lab services. 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 waive the 
copayment for lab services provided on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on July 22, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that the test was supposed to be 
completed at another visit, and you should not be charged for having to return. 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 $45 
copayment for physician/practitioner services, including doctors office visits (specialist). 
 
You have been asked to pay a $45 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits (specialist) benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the office visit provided on July 22, 2022.
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 the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says that continued SNF care is not 
medically necessary. 
 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 that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 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 pay for SNF care provided from June 4, 2022, to July 3, 2022. 
 You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says skilled nursing facility care is no 
longer needed. 
 
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 pay for 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 that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from June 4, 2022, to July 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided on 
October 19, 2022. 
 
You asked the Plan to waive the copayment for an outpatient hospital visit. You say that you are disputing the 
share cost. 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 $225 
copayment for Outpatient hospital services. 
 
You have been asked to pay a $225 copayment for an outpatient hospital visit. This item/service falls within the 
Outpatient hospital 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 
outpatient hospital visit provided on October 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray provided on September 12, 2022. 
 
You asked the Plan to waive the copayment for x-ray. You say that you are disputing the share cost. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $40 copayment for x-ray. 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 waive the copayment 
for x-ray provided on September 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle foot orthosis (L1971) and a heel stabilizer (L3170) 
provided on June 21, 2022. 
 
You asked the Plan to pay for the ankle foot orthosis and the heel stabilizer. You say that the records provided 
support the items in dispute. The Plan denied your request. The Plan says the documentation submitted did not 
sufficiently support the billed supply codes. 
 
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 pay for the ankle foot orthosis and the heel 
stabilizer. Our reviewer says that the ankle foot orthosis and the heel stabilizer are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the most recent medical chart note 
enclosed in this case is dated February 15, 2022.  After review of this chart note, there is no mention of ankle 
pain or a physical exam noting ankle pathology.  While there is a prescription for an ankle foot orthosis with 
heel stabilizer dated May 23, 2022, there is no proof of delivery for the items in dispute. Absent in the medical 
documentation is a physical examination of the patients ankle, and proof of dispensing of these devices. 
 
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 ankle foot orthosis and the heel stabilizer have not been met. Therefore, we 
decided that the Plan does not have to pay for an ankle foot orthosis (L1971) and a heel stabilizer (L3170) 
provided on June 21, 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 would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee can safely receive the care they need in the current 
hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has stage 4 chronic obstructive 
pulmonary disease (COPD) with chronic respiratory failure with hypoxia and chronic respiratory failure with 
hypercapnia. You say that the enrollee has had increased oxygen needs and a severe decline in her condition 
without the appropriate therapy. You say that the enrollee has tried bi-level positive airway pressure (BiPAP) 
and remained extremely hypoxic, which was proven through arterial blood gas (ABG). You say that the 
enrollee will die without the requested equipment. The Plan denied your request. The Plan says the requested 
home ventilator would be set in intelligent volume-assured pressure support (iVAPS) mode with Auto- 
expiratory positive airway pressure (EPAP) that could be delivered by BiPAP and is therefore not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary.  This patient has COPD, interstitial lung disease, and pulmonary hypertension with heart 
failure.  ABG while acutely ill was consistent with acute on chronic hypercarbic respiratory failure.  This 
patient may benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep as an 
outpatient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.