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

 
We decided that the Plan does not have to waive the copayment for a blood specimen taken from a port 
provided on July 27, 2022. 
 
You asked the Plan to waive the copayment for a blood specimen taken from a port. You say that this is a large 
charge. Would it have been this much if I had it done in my arm or elbow? 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 $325 
copayment for outpatient surgery. You have been charged this amount as an outpatient hospital facility because 
it was drawn in the infusion center. 
 
You have been asked to pay the allowed amount of $116.69 which is less than the $325 copayment for a blood 
specimen taken from a port. This item/service falls within the outpatient surgery 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 blood specimen taken from a port provided on July 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for two therapy visits after knee surgery 
provided from June 21, 2022, to June 22, 2022. 
 
You asked the Plan to waive the copayment for two therapy visits after knee surgery. You say that you never 
had therapy visits after this procedure. 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 $30 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $60 copayment for two therapy visits after knee surgery ($250 surgical 
copayment + $60 = $310). This item/service falls within the outpatient rehabilitation 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 two therapy visits after knee surgery provided 
from June 21, 2022, to June 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for part B drugs and diagnostic test on July 18, 
2022. 
 
You asked the Plan to waive the cost share for part B drugs and diagnostic test. You say that you want to 
appeal the amount being charged. 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 20% 
coinsurance for Medicare Part B prescription drugs. Covered drugs include drugs that usually arent self-
administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or 
ambulatory surgical center services. You must pay a $150 copayment for CT, MRI, MRA, and SPECT scans. 
Covered services include but are not limited to advanced radiology services (CT, MRI, MRA, SPECT, PET). 
The provider billed in the amount of $540 and the allowed amount is $245.90. $245.90 x 20% = $49.18. $150 
+ $49.18 = $199.18. Therefore, results in the total cost sharing amount of $199.18. 
 
You have been asked to pay a 20% coinsurance for part B drugs and a $150 copayment for diagnostic test. This 
item/service 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 waive the cost share for part B drugs 
and diagnostic test on July 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
January 26, 2022 to February 7, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
covered as you disagree with the charges. 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 enrollees must pay a 
$275 copayment per day for days 1-5 of Inpatient hospital care. 
 
  You have been asked to pay a $1,375 copayment for the inpatient hospital stay. This item/service 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 stay provided from January 26, 2022 to February 7, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429), and ground mileage (A0425) provided on June 19, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not enrolled in hospice on 
the date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 2, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance service, 
basic life support, emergency transport (A0429), and ground mileage (A0425) provided on June 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit (99335) provided on July 15, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that this service was medically 
necessary. The Plan denied your request. The Plan says this service was not urgent or emergent in nature. The 
Plan also says prior authorization was not 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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 the domiciliary visit (99335) provided on July 15, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the coinsurance for chemotherapy services rendered on 
October 18, 2021, and November 8, 2021.  
 
You asked the Plan to adjust the coinsurance for chemotherapy services. You say that you are asking for an 
adjustment that reflects what you were charged starting in January 2022. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay $1,620.06 for chemotherapy services provided on October 19, 2021. You have 
also been asked to pay $1,519.94, which is less than the standard coinsurance for chemotherapy services 
provided on November 8, 2021 because you met your maximum out-of-pocket. This item/service falls within 
the Medicare Part B prescription drugs benefit category.  
Date of Service Service Plan Allowance Cost Per Contract 
Your 
Responsibility 
October 18, 2021 Medicare Part B Drug $386.30 20% Coinsurance $77.26 
October 18, 2021 Drug Administration $7,714.00 20% Coinsurance $1,542.80 
November 8, 2021 Medicare Part B Drug $386.30 20% Coinsurance $77.26 
November 8, 2021 Drug Administration $7,714.00 20% Coinsurance $1,442.68 
TOTAL    $3,140.00 
  
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 adjust the coinsurance for chemotherapy services rendered on October 18, 2021, and 
November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on June 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for anesthesia services. You say that it is beyond your control to obtain 
authorizations/referrals for patients that you are unaware will become a part of your daily caseload. The Plan 
denied your request. The Plan says This provider is not a network provider with the Plan. The Plan also says 
that these services 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 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 anesthesia services provided on June 15, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair (PWC) 
(K0807). 
 
You asked the Plan to pre-approve a group 2 heavy duty PWC. You say that the item is medically necessary. 
The Plan denied your request. The Plan says you do not meet the criteria for a heavy-duty power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that the beneficiarys weight must be less than or 
equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 95% of the 
weight capacity of the next lower weight class PWC  i.e., a Heavy Duty PWC is covered for a beneficiary 
weighing 285  450 pounds; a Very Heavy Duty PWC is covered for a beneficiary weighing 428  600 pounds; 
an Extra Heavy Duty PWC is covered for a beneficiary weighing 570 pounds or more. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 2 heavy duty PWC have not been met. Specifically, you do not meet the weight 
requirement for this item. Therefore, we decided that the Plan does not have to pre-approve a group 2 heavy 
duty power wheelchair (PWC) (K0807).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leg brace (L1852), to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a leg brace. You say that you need this item. The Plan denied your request. 
The Plan says there are in-network providers available to obtain this item. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a leg brace (L1852), to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the request is not medically necessary, the enrollee can safely receive the 
services you need in other settings, for example: a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote patient monitoring services provided on May 9, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for remote patient monitoring services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee can get care from a network provider and 
there was no prior authorization on file. 
 
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 remote patient monitoring services provided on 
May 9, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total shoulder arthroplasty. 
 
You asked the Plan to pre-approve total shoulder arthroplasty. You say that the enrollee needs this surgery to 
regain function. The Plan denied your request. The Plan says this surgery is not medically necessary. 
 
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 pre-approve total shoulder arthroplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation is not evident regarding diagnostic imaging 
corroboration of symptomatic large and massive rotator cuff tears. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale or extenuating circumstance noted to support the necessity of this request as an exception 
to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of total shoulder arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve total shoulder arthroplasty.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a total abdominal hysterectomy. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has a thickened 
endometrium. The Plan denied your request. The Plan says that the enrollee is not having significant symptoms 
from leiomyoma. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 requested services. Our physician 
reviewer found that the enrollee has rectal adenocarcinoma with distant metastases. The enrollee has had 
chemotherapy, radiation and partial hepatectomy and is scheduled for low anterior resection and intraoperative 
radiation. The record indicates that the endometrial stripe has doubled in thickness. Given the fact that the 
enrollee is already undergoing exploration and has pelvic disease, it is medically reasonable to perform 
hysterectomy at the same time. The record establishes the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are satisfied. The requested 
service is recommended. 
 
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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve a total abdominal hysterectomy.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued skilled nursing facility (SNF) services provided to 
the enrollee from June 1, 2022, to June 13, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from January 5, 2022, 
to May 31, 2022. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for continued skilled nursing facility (SNF) services provided to the enrollee 
from June 1, 2022, to June 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the requested CGM. You say that you feel that this is necessary. The Plan 
denied your request. The Plan says the records available do not show that you use insulin. This can only be 
covered if you require at least three insulin administrations per day. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
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 assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. The Plan requested records from the ordering physician, but these were not 
submitted. Based on this information, we decided that Medicare rules for coverage of the requested CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
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 May 1, 2022, to May 6, 2022. 
 
You asked the Plan to waive the copayment for the SNF care. You say that the services should be covered as 
you disagree with the denial. 
 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 $188 
copayment per day for days 21-100 of Skilled nursing facility (SNF) care.  
 
 
  You have been asked to pay a $940 copayment for 5 days of SNF care. This item/service 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 May 1, 2022, to May 6, 2022.