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

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
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 medically reasonable and necessary. Our physician reviewer found that based on the 
documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs, 
custodial and intermittent, can, as a practical matter, 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 admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient rehabilitation admission to be provided by 
the requested out-of-network provider at the in-network benefit level. 
 
You asked the Plan to pre-approve an inpatient rehabilitation admission to be provided by the requested  
out-of-network provider at the in-network benefit level. You say that there are no in-network facilities in the 
parish. The Plan denied your request. The Plan says although the member has a Point-of-Service Benefit and 
this benefit allows the member to receive services from non-contracted providers, there are two  
in-network inpatient rehabilitation facilities in Shreveport that are available for Plan members. Therefore, an 
in-network exception is not warranted. 
 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 an 
inpatient rehabilitation admission to be provided by the requested out-of-network provider at the in-network 
benefit level.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobile electrocardiogram provided on February 8, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that you provide immediate services per referring 
providers' requests. Your company has an exclusive contract with the facility the enrollee was present in. This 
should be covered as authorization is the facility's responsibility. The Plan denied your request. The Plan says 
this was not an emergency service, and no authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the mobile electrocardiogram provided on 
February 8, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an out-of-network (OON) specialist office 
visit provided on April 7, 2022. 
 
You asked the Plan to waive the deductible for the OON specialist visit. You say that the provider moved but 
should still be in-network. The Plan denied your request. The Plan says the correct amount was applied to your 
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 $490 in-network and out-of-network combined deductible which 
applies to certain items and services.  
 
The file shows that the Plan verified the provider is not a network provider. The OON specialist visit falls 
within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is $490 in-network and out-of-network 
combined deductible which applies to certain items and services. This cost sharing is a contractual obligation 
that had not been met at the time the OON specialist visit was received on April 7, 2022. Therefore, we decided 
that the Plan does not have to waive the deductible for an out-of-network (OON) specialist office visit provided 
on April 7, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies provided by home care from May 30, 2021, to  
June 1, 2021. 
 
You asked the Plan to pay for supplies provided by home care. The Plan denied your request. The Plan says the 
provider will need to bill Medicare directly for the services rendered. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for supplies provided by home care from May 30, 2021, to 
June 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care services provided on April 12, 
2022. 
 
You asked the Plan to waive the copayment for the wound care. You say that the wound care should be 
covered. 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 $325 
copayment per visit for surgery or services at an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay a $325 copayment for the wound care. The wound care 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 copayment for wound care services provided on April 12, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a COVID-19 at-home test kit provided on  
January 24, 2022. 
 
You asked the Plan to reimburse you for a COVID-19 at-home test kit. The Plan denied your request. The Plan 
says the tests were purchased prior to the benefit effective date. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. The file shows the test kit was purchased prior to the benefit effective 
date. Based on this information, we decided that Medicare rules for coverage of a COVID-19 at-home test kit 
have not been met. Therefore, we decided that the Plan does not have to reimburse you for a COVID-19 at-
home test kit provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a joint injection performed on April 22, 
2022. 
 
You asked the Plan to waive the copayment for the injection. You say that you were not charged for this 
procedure before and feel it was coded incorrectly. 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 $350 
copayment per visit for surgery or services at a hospital outpatient facility or ambulatory surgical center.  
 
You have been asked to pay a total of $294.63, which is less than the $350 copayment for the injection. The 
injection 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 copayment for a joint 
injection performed on April 22, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
January 3, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were waiting too long and left 
without being seen. 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 $90 
copayment for each emergency room visit.  
 
The records show that you were evaluated by triage staff. Therefore, you have been asked to pay 68.16, which 
is less than the $90 copayment for the ER visit. The ER visit falls within the Emergency 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 an emergency room (ER) visit provided on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to approve a referral to an out-of-network provider at the in-network 
rate. 
 
You asked the Plan to approve these services. You say that the provider specializes in pancreatic cancer. The 
Plan denied your request. The Plan says the services are available from network providers at the in-network 
rate. 
 
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 50% of 
the Medicare-allowed amount for out-of-network specialist visit for Medicare-covered services.  
 
The requested provider is not in the Plans network. If you choose to receive services with this provider, you 
will be asked to pay 50% of the Medicare-allowed amount for these services. These services fall within the out-
of-network specialist visit for Medicare-covered services benefit category. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The Plan has network providers available that you can see at the in-network rate. Therefore, we decided that the Plan does not have to approve a referral to an out-
of-network provider at the in-network rate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. You say that you do not have 
another form of reliable transportation and you need the additional rides in order to attend your physical 
therapy appointments. The Plan denied your request. The Plan says there is not an exception that would allow 
the Plan to approve additional rides to other health care locations as requested by the member. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  We looked at your request, the records in the case file, and the rules. The file shows that the Plan does not 
cover more than 30 one-way rides per year. Therefore, we decided that the Plan does not have to provide 
coverage for additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
March 21, 2022. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that the call was only a 
consult and you were informed that you were not due for the colonoscopy until next year. 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 $45 
copayment for specialist services, including telehealth.  
 
You have been asked to pay a $45 copayment for the specialist telehealth visit. The specialist telehealth visit 
falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 specialist telehealth visit provided on March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 24, 2022. 
 
You asked the Plan to pay for an office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says services from non-participating providers are not covered under open access 
unless preauthorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the humidifier provided on January 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the humidifier. You say that the service was previously paid, and the service was 
medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
humidifier. We found no exception that would require the Plan to pay for the humidifier. The records provided 
for review do not show that the humidifier was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the humidifier provided on January 26, 2022, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous immune-globulin (IVIG). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that IVIG is covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has cerebellar ataxia with 
involuntary movements and ataxia. She was found to have an anti-Ri antibody, suspicious for paraneoplastic 
ataxia. She received several doses of IVIG in the hospital with reported improvement in her condition; 
however, the documentation is insufficient to demonstrate that IVIG is medically reasonable and necessary for 
the enrollees condition. The Food and Drug Administration (FDA) has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive 
citation for the use of the requested drug for the treatment of the enrollee's clinical condition. The noted 
condition is not one for which coverage is available under the Medicare criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intravenous immune-globulin (IVIG).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
March 5, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. 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 each one-way ambulance trip.  
 
You have been asked to pay a $175 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 
ambulance transportation provided on March 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extracorporeal shock wave therapy (ESWT) for the treatment 
of erectile dysfunction provided on December 7, 2021. 
 
You asked the Plan to pay for ESWT. You say that ESWT was medically necessary after prostate surgery. The 
Plan denied your request. The Plan says ESWT for the treatment of erectile dysfunction is not medically 
necessary and therefore not covered. There is a lack of long-term studies supporting this service and it has not 
been approved by the Food and Drug Administration for this condition. 
 
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 ESWT. Our reviewer says that ESWT is not 
considered medically reasonable and necessary in this case. Our physician reviewer found acoustic wave 
therapy is considered experimental and investigational for erectile dysfunction because of a lack of evidence 
from prospective randomized controlled clinical studies of the effectiveness for this indication. The most recent 
American Urological Association guideline concerning erectile dysfunction gives acoustic wave therapy a 
grade C recommendation and it should be considered investigational.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ESWT have not been met. Therefore, we decided that the Plan does not have to 
pay for extracorporeal shock wave therapy (ESWT) for the treatment of erectile dysfunction provided on 
December 7, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from February 3, 2022, to February 26, 2022. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you were in a nursing home and had 
no way of getting to another doctor. 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 $0 per 
day for days 1-20 and $180 per day for days 21-100 for each benefit period. 
 
Dates of Service Benefit Days Copayment 
February 3, 2022  February 22, 2022 1-20 $0/day 
February 23, 2022  February 25, 2022 21-23 $180/day 
Total:  $540 Since there is no copayment for the discharge date, you have been asked to pay $180 per day for days 21-23 of 
SNF care. The total for the stay is $540. The SNF care falls within the Skilled Nursing Facility (SNF) 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 skilled nursing facility (SNF) 
care provided from February 3, 2022, to February 26, 2022.