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

 
We decided that the Plan does not have to pay for radiation therapy services provided on September 7, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for radiation therapy services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
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 radiation therapy services provided on September 
7, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for rehabilitation services provided from 
March 11, 2022, to March 15, 2022. 
 
You asked the Plan to waive the copayment for the rehabilitation services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $35 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $175 copayment for 5 rehabilitation service visits ($35 x 5 = $175). 
Rehabilitation services fall 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 rehabilitation services provided from March 11, 2022, to March 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance on August 30, 2021. 
 
You asked the Plan to waive the copayment for an ambulance. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the copayment applied 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 a $265 
copayment for an ambulance. Both, in-network and out-of-network ambulance services, have a $265 
copayment. 
 
You have been asked to pay a $265 copayment for an ambulance. An ambulance 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 an ambulance on August 
30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injection services. 
 
You asked the Plan to pre-approve repeat epidural steroid injection services. You say that this repeat injection 
is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
satisfied. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat ESI services can be approved when the 
medical records document at least 50% of sustained improvement in pain relief and/or improvement in function 
measured from baseline for at least three months 
 
We looked at the file and Medicare rules. In this case, the record indicates the first injection was performed in 
June 2022. Three month have not passed since the first injection. Based on this information, we decided that 
Medicare rules for coverage of repeat epidural steroid injection services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve repeat epidural steroid injection services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
April 9, 2021, through April 12, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $370 
copayment each day, for days 1 to 5 for in-network Medicare-covered hospital care and a $0 copayment for 
additional Medicare-covered days.  
 
You have been asked to pay $1,110 ($370 copayment x 3 days) for the inpatient hospital care provided. 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 inpatient hospital care 
provided from April 9, 2021, through April 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that there is not a skilled nursing facility that 
will take the enrollee's medical condition. The Plan denied your request. The Plan says the enrollee does not 
meet criteria, is not medically necessary, and continued acute hospital stay was offered until the enrollee can 
discharge to a lower level of care. 
 
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 the enrollee is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5225) provided on January 12, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you had to see another dentist to get dentures 
that fit better. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 7, 2021. Therefore, 
we decided that the Plan does not have to pay for a maxillary partial denture (D5225) provided on January 12, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
October 8, 2021, to October 12, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you had to stay an extra day 
and you should not be charged. 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 $360 per 
day for days 1-5 and $0 per day after day 5 for each inpatient admission.  
 
The file shows that you were in the hospital from October 8, 2021, to October 12, 2021, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $360 per day for the first 4 days of 
inpatient care. The total for your stay is $1,440 ($360 copayment x 4 days = $1,440). The inpatient care falls 
within the Inpatient Hospital 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 
inpatient hospital care provided from October 8, 2021, to October 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
transfer to LTAC. She cannot be adequately cared for in her current condition at a skilled nursing facility. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient care and is currently 
unstable for transfer to an LTACH. 
 
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 the enrollee appears to be stable and improving on current treatment and should only 
require short-term additional acute care hospital services that can be safely administered at the current facility 
until more appropriate for 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
December 6, 2021, through December 31, 2021. 
 You asked the Plan to pay for the SNF care. You say that the provided SNF care was medically reasonable and 
necessary. The Plan denied your request. The Plan says the SNF care provided was not medically reasonable 
and necessary during the dates in question. 
 
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 the SNF care. Our reviewer says that the 
requested SNF care was not medically reasonable and necessary. Our physician reviewer found the beneficiary 
was a 71-year-old female with quadriplegia, treated for fever and leukocytosis and urinary tract infection. In 
this case, there were no identifiable skilled nursing service needs and no identifiable skilled therapy service 
needs. Therefore, the beneficiary did not meet severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from December 6, 2021, through December 31, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care services provided on January 
14, 2022. 
 
You asked the Plan to waive the copayment for the wound care. You say that the enrollee should not have been 
responsible since the wounds were a result of improper care. The Plan denied your request. The Plan says the 
enrollee was charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for surgery or services provided at an outpatient hospital or ambulatory surgical 
center.  
 
The enrollee was asked to pay a $250 copayment for the wound care. The wound care falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. This means that the enrollee was asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for wound care 
services provided on January 14, 2022.
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 August 27, 
2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you were not examined and 
only had a COVID-19 test done. 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 each urgent care visit.  
 
You have been asked to pay $20, which is less than the $50 copayment for the urgent care visit. The 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 August 27, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Euflexxa. 
 
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 that the step therapy requirement is not met. 
 
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. The Plan states that the services are not medically necessary because the step 
therapy drugs have not been tried or failed; however, there are no submitted medical records. Without medical 
records, a determination based on medical necessity cannot be supported. Therefore, we decided that the Plan 
has to pre-approve Euflexxa.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
March 7, 2022. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you did not see or call the 
provider on this day. 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 $5 
copayment for specialist telehealth services.  
 
The record shows that you were evaluated by telehealth services on March 7, 2022. Therefore, you have been 
asked to pay a $5 copayment for the telehealth visit. The 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 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on June 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the Plan did not have a contracted provider 
available to render services. The Plan denied your request. The Plan says the services were provided out-of-
network and were not approved in advance. 
 
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 
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 nursing facility care provided on June 1, 2021, by 
an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network (OON) psychotherapy 
services provided on November 24, 2021. 
 
You asked the Plan to waive the copayment for the OON psychotherapy services. You say that you were 
informed that the provider was in-network. 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 $55 
copayment for each therapy visit with an out-of-network provider.  
 The file shows that the Plan verified the provider is not a network provider. Therefore, you have been asked to 
pay a $55 copayment for the OON psychotherapy services. The OON psychotherapy services fall 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 
out-of-network (OON) psychotherapy services provided on November 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox Injections. 
 
You asked the Plan to pre-approve the Botox Injections. You say that you would like reconsideration because 
the Botox Injections are medically necessary. The Plan denied your request. The Plan says further need for 
treatment was not indicated given the enrollee's pain reduction. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Botox Injections. Our reviewer says 
that based on the occupational therapy and medical records provided there is inadequate documentation that the 
repeat Botox injections meet Medicare criteria for medically reasonable and necessary. Our physician reviewer 
found provided records document the enrollee met all of his occupational therapy goals for upper body 
strength, range of motion and activity tolerance, home exercise program and transfer ability at a 07/05/2022 
visit and he has no pain issues. 
 
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 Botox Injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Botox Injections.