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

 
We decided that the Plan does not have to pay for anticoagulant management for a patient taking warfarin and a 
prothrombin time test provided on March 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for anticoagulant management for a patient taking warfarin and a prothrombin time 
test. You say that you are appealing with supporting documents. The Plan denied your request. The Plan says 
this provider is not a network provider with the Plan and the services were not referred by a network provider 
or rendered in an in-network facility. The Plan also says that they have also determined that these services are 
not urgent or emergent, nor were they 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 anticoagulant management for a patient taking 
warfarin and a prothrombin time test provided on March 16, 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 coinsurance for an aflibercept injection provided on 
September 1, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you are on a fixed income and 
cannot afford the coinsurance. 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 20% 
coinsurance for each Part B drug.  
 
You have been asked to pay $367.55, which is 20% of the allowed amount for the injection ($1,837.74 allowed 
amount x 20% coinsurance = $367.55). The injection 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 an aflibercept injection 
provided on September 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient stay from February 
12, 2022, to February 16, 2022. 
 
You asked the Plan to waive the copayment for an in-network inpatient stay. You say that you should not have 
to pay this amount as the injury that caused you to stay at the hospital happened at a place of business. The Plan 
denied your request. The Plan says the copayment applied was 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 $350 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $1400 copayment for an in-network inpatient stay ($350 x 4 = $1400). An in-
network inpatient stay 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 an in-network inpatient stay from February 12, 2022, to February 16, 2022.  
 Your complaint about sustaining this injury at a place of business is not a valid appeal for medical coverage. 
Please follow up with them. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
January 28, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that your primary care office was closed 
and you had no other alternatives to be 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 $35 
copayment for each emergency room visit.  
 
You have been asked to pay a $35 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 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that manual wheelchairs are only covered under 
certain medical indications. 
 
We looked at the file and Medicare rules. The medical records show that you are able to ambulate with a cane. 
Based on this information, we decided that Medicare rules for coverage of the requested wheelchair have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a comprehensive electrophysiologic 
evaluation provided on September 8, 2021. 
 
You asked the Plan to waive the coinsurance for the evaluation. You say that the test had to be done to 
complete your procedure. 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 20% 
coinsurance for diagnostic procedures and tests at an outpatient hospital.  
 
You have been asked to pay $3,800.03, which is less than 20% of the allowed amount for the evaluation 
($19,300.80 allowed amount x 20% coinsurance = $3,860.16). The evaluation falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for a comprehensive electrophysiologic evaluation provided on September 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex implant device. 
 
You asked the Plan to pre-approve Vertiflex implant device. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are 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 Vertiflex implant device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic low back pain with pain radiating into the buttocks. The 
enrollee has tried medication, physical therapy, and injections without improvement to the enrollee's 
symptoms. The Vertiflex device is considered experimental. Therefore, the enrollee does not meet criteria for 
the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex implant device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Vertiflex implant device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage for durable medical 
equipment have not been met. 
 
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 portable oxygen concentrator (E1392).
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 1, 2022, to February 2, 2022. 
 
You asked the Plan to waive the copayment for the SNF care. You say that these dates should have been 
covered under the first 20 days. The Plan denied your request. The Plan says the enrollee has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 per day for days 1-20, $188 per day for days 21-44, and $0 per day for days 45-100 for each 
benefit period. 
 
 
 
 Dates of service Benefit Period Days Copayment per EOC 
January 13, 2022  February 1, 2022 1-20 $0/day 
February 2, 2022 21 $188/day 
Total:  $188 
 
The file shows that the enrollee was in the nursing facility from January 13, 2022, to February 2, 2022. The 
enrollee has been asked to pay $188 per day for day 21 of SNF care. The SNF care falls within the Skilled 
Nursing Facility (SNF) 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 copayment for 
skilled nursing facility (SNF) care provided from February 1, 2022, to February 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the full criteria for an IRF stay. 
The Plan denied your request. The Plan says the documentation provided does not show that the enrollee is able 
to take part in 3 hours of therapy a day at least 5 days a week or 15 hours per week. The enrollee needs physical 
and occupational therapy. The services the enrollee needs can be provided safely in other settings like a skilled 
nursing facility, home with home health services or home with outpatient therapy. 
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for a scheduled knee replacement. Medical problems are stable. There are no complex 
nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility stay provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve a skilled nursing facility stay. You say that an SNF admission is medically 
necessary. The Plan denied your request. The Plan says the medical criteria for an SNF admission has 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 a skilled nursing facility stay. Our 
reviewer says that an SNF admission is not medically necessary. Our physician reviewer found the enrollee is 
medically stable and does not have any complex daily wound care, parental medications or required care for a 
new or malfunctioning feeding tube. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a skilled nursing facility stay have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a skilled nursing facility stay provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair options and accessories. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair options and accessories are only 
covered under certain medical indications.  The file shows that a power seat elevation system, transfer handles, and push handles were requested. These 
items are non-covered because they are not primarily medical in nature. Arm pads and elbow supports were 
also requested. These items are included in approved codes and are not separately reportable. Based on this 
information, we decided that Medicare rules for coverage of the requested services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve wheelchair options and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says facet joint injections do not meet the Medicare LCD 
coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found that there is no documentation at all about the duration and degree of pain relief after the last injections. Therefore, the criteria 
are not met and the request is deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on March 3, 2022, to March 31, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy. 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 physical therapy provided on March 3, 2022, to 
March 31, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trigger point injections to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve trigger point injections. You say that the enrollee prefers to have this 
provider perform the injection. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an 
in-network provider. 
 
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 
trigger point injections to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a euflexxa injection provided on February 
4, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you cannot afford the coinsurance. 
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 20% 
coinsurance for all Part B drugs.  
 
You have been asked to pay $147.76, which is 20% of the allowed amount for the injection ($738.82 allowed 
amount x 20% coinsurance = $147.76). The injection 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 euflexxa injection provided on 
February 4, 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), ground mileage (A0425), and supplies (A0382) provided on November 27, 2021. 
 
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 November 11, 2021. 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), ground mileage (A0425), and supplies (A0382) 
provided on November 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the medical criteria for an IRF admission have not been met. 
 
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 enrollee was admitted for anemia secondary to bleeding from a scalp laceration. Medical problems are stable and there are no complex nursing or rehabilitation needs. 
 
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 inpatient rehabilitation facility (IRF) admission and services.