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

 
We decided that the Plan does not have to waive the coinsurance for a genvisc joint injection with fluoroscopic 
guidance performed by an out-of-network (OON) provider on August 31, 2021. 
 
You asked the Plan to waive the coinsurance for the OON injection with fluoroscopic guidance. You say that 
you were informed that all costs would be covered. The Plan denied your request. The Plan says the correct 
coinsurance 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 50% 
coinsurance for surgery or services at an out-of-network (OON) outpatient hospital or ambulatory surgical 
center. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for diagnostic procedures 
and tests at an out-of-network (OON) facility. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for Part B drugs received at 
an out-of-network (OON) facility. 
 
Service/Drug Allowed Amount 50% Coinsurance (OON) 
Injection Procedure $59.68 $29.84 
Fluoroscopic Guidance $107.47 $53.73 
Genvisc Drug $411.00 $205.50 
Total:  $289.07 
 
You have been asked to pay $289.07, which is 50% of the allowed amount for the OON injection with 
fluoroscopic guidance. The injection procedure falls within the Outpatient Surgery, Including Service Provided 
at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The fluoroscopic guidance 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The 
genvisc drug falls within the Medicare Part B Prescription Drugs benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for a genvisc joint injection with fluoroscopic guidance performed by an out-of-
network (OON) provider on August 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a genvisc joint injection with fluoroscopic 
guidance performed by an out-of-network (OON) provider on December 8, 2020. 
 
You asked the Plan to waive the coinsurance for the OON injection with fluoroscopic guidance. You say that 
you were informed that all costs would be covered. The Plan denied your request. The Plan says the correct 
coinsurance 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 50% 
coinsurance for surgery or services at an out-of-network (OON) outpatient hospital or ambulatory surgical 
center. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for diagnostic procedures 
and tests at an out-of-network (OON) facility. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for Part B drugs received at 
an out-of-network (OON) facility. 
 
Service/Drug Allowed Amount 50% Coinsurance (OON) 
Injection Procedure $87.84 43.92 
Fluoroscopic Guidance $100.18 $50.09 
Genvisc Drug $822.00 $411.00 
Total:  $505.01 
 
You have been asked to pay $505.01, which is 50% of the allowed amount for the OON injection with 
fluoroscopic guidance. The injection procedure falls within the Outpatient Surgery, Including Service Provided 
at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The fluoroscopic guidance 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The 
genvisc drug falls within the Medicare Part B Prescription Drugs benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for a genvisc joint injection with fluoroscopic guidance performed by an out-of-
network (OON) provider on December 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a folding travel scooter. 
 
You asked the Plan to pre-approve a folding travel scooter. You say that your current scooter will not fir in 
your car or support a hitch. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
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 folding travel scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exercise pool with handicap accessibility railing and 
wheelchair ramp. 
 
You asked the Plan to pre-approve these services. You say that you need to exercise to help your activity and 
strength. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve an exercise pool with handicap accessibility railing and 
wheelchair ramp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $202.17 copayment for infusion therapy received on 
January 12, 2022. 
 
You asked the Plan to waive the $202.17 copayment for infusion therapy received on January 12, 2022. You 
say that you want to know why this amount wasn't covered. The Plan denied your request. The Plan says you 
pay a $295 copayment for Medicare-covered surgery or other services provided at an outpatient hospital.  
 
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 $295 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $202.17 copayment for infusion therapy. Infusion therapy falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. For this service, the provider billed $349; the Plans allowance was $202.17. 
Since the allowed amount is less than your required copayment, you were only asked to pay the lesser amount. 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 $202.17 copayment for infusion therapy received on January 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $200 copayment for an inpatient hospital stay from 
January 5, 2022, to January 10, 2022. 
 
You asked the Plan to waive the $200 copayment for an inpatient hospital stay from January 5, 2022, to 
January 10, 2022. You say that you have never had to pay for services before now. The Plan denied your 
request. The Plan says you pay a $200 copayment for in-network medically necessary inpatient hospital care. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $200 copayment for Inpatient Hospital Care.  
 
The enrollee has been asked to pay a $200 copayment for an inpatient hospital stay. An inpatient hospital stay 
falls within the Inpatient Hospital 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 $200 
copayment for an inpatient hospital stay from January 5, 2022, to January 10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible  for physical therapy rendered on  
January 11, 2022. 
 
You asked the Plan to waive the deductible for physical therapy services rendered on January 11, 2022. You 
say that you have already paid a $40 copayment for this service. The Plan denied your request. The Plan says 
you have a $300 combined in-network and out-of-network deductible. 
 
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 $300 combined in-network and out-of-network deductible which 
applies to outpatient rehabilitation Services.  
 
The item or service you asked the Plan to waive the deductible for falls within Outpatient Rehabilitation 
Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that the $300 deductible applies to outpatient rehabilitation services. This cost sharing is a contractual obligation that 
had not been met at the time physical therapy was received on January 11, 2022. Contact the Plan regarding the 
amount still owed toward the deductible for this service. Therefore, we decided that the Plan does not have to 
waive the deductible  for physical therapy provided on January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a personal emergency response system. 
 
You asked the Plan to pre-approve a personal emergency response system. You say that you need this due to 
frequent falls. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also say that Telephone Alert Systems are emergency communications systems and 
do not serve a diagnostic or therapeutic purpose.  
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a personal emergency response system.
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 SNF care is medically necessary as you believe 
the enrollee would benefit from care at the SNF. The Plan denied your request. The Plan says SNF care is not 
reasonable and necessary and does not meet Medicare criteria for coverage under the Medicare Part A benefit. 
 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 
SNF services are not medically necessary. Our physician reviewer found that based on the documentation 
provided, the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs are custodial and can, as a practical matter, be provided at a lower level of care  
(ex. home, assisted living, long term 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a LifeVest provided January 4, 2022, and 
February 4, 2022. 
 
You asked the Plan to waive the coinsurance for a LifeVest. You say that you were not aware of the cost. The 
Plan denied your request. The Plan says you pay a 20% coinsurance for durable medical equipment. 
 
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 20% 
coinsurance for Durable Medical Equipment (DME) and Related Supplies.  
 
You have been asked to pay a $649.58 coinsurance for a LifeVest supplied on January 4, 2022, and  
February 4, 2022. The allowed amount for this equipment is $3,247.91. 20% of $3,247.91 is $649.58. A 
LifeVest falls 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 a LifeVest provided January 4, 2022, and February 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sock aid and foot scrubber. 
 
You asked the Plan to pre-approve a sock aid and foot scrubber. You say that you need these items because you 
cannot bend, twist, or lift. The Plan denied your request. The Plan says these items are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a sock aid and foot scrubber.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested provider. The Plan 
denied your request. The Plan says the medical group approved you to see this provider for a second opinion 
visit only. The treatment and follow up is not different from the orders received from the contracted provider. 
Because the medical group has in-network oncologist able to provide the requested services, the request to go 
out of network is denied. 
 
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 services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the requested home health services are 
medically necessary. The Plan denied your request. The Plan says the requested home health services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found based 
on the documentation provided, the enrollee currently does not have documented skilled nursing needs. The 
enrollee currently does not have documented skilled therapy needs. The requested home health services are 
custodial and are not medically necessary or reasonable to assist in the treatment of acute illness or injury. As such, the requested home health services are not coverable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF care is medically necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines, the SNF services you are requesting do not 
meet the requirements for approval. 
 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 
SNF services are not medically necessary. Our physician reviewer found that based on the documentation 
provided, the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled 
nursing needs. The enrollees percutaneous endoscopic gastrostomy (PEG) tube is established. The enrollee is 
not receiving complex wound care. The enrollee does not have documented skilled therapy needs. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs, custodial and long-term, can, as a practical matter, be provided at a lower 
level of care (ex. long term 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the urgent care visit. We also decided that the Plan 
does not have to fully waive the copayment for the urgent care visit.  
 
You asked the Plan to waive the copayment for the urgent care visit. You say that the wait time was excessive 
and they were not able to treat you. The Plan says that you have been charged the correct cost sharing amount. 
 
 
 We decided that the Plan has to reduce the copayment for the urgent care visit.  
 
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 Plan says that you must pay a $45 copayment for the urgent 
care visit. Based on the Plan contract, however, you cannot be asked to pay more than a $25 copayment for 
urgently needed services at an urgent care center. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan has to reduce the copayment for the 
urgent care visit from $45 to $25. 
 
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 pre-approve BRCA genetic testing. 
 
You asked the Plan to pre-approve these services. You say that your doctor suggested the testing. The Plan 
denied your request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA testing of an unaffected Medicare eligible 
individual or family member is not a covered Medicare benefit. 
 
We looked at the file and Medicare rules. The file shows that you do not have a personal history of cancer for 
which BRCA testing is covered. Therefore, we decided that the Plan does not have to pre-approve BRCA 
genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM) 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 CGM. You say that you had been approved for the strips 
but need the monitor receiver and sensor to use it. The Plan denied your request. The Plan says you do not meet 
criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre 2 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle 
Libre 2 continuous glucose monitor (CGM)