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

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 15, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the claim shows a 
patient responsibility of $0. 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 services obtained from a specialist.  
 
 
 You have been asked to pay a $35 copayment for the specialist office visit. The specialist office 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 office visit provided on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments and coinsurance for eye exams and 
bevacizumab injections provided from January 12, 2021, to December 14, 2021. 
 
You asked the Plan to waive the copayments and coinsurance for the eye exams and injections. You say that 
you only had a $15 copayment for these services last year. The Plan denied your request. The Plan says the 
correct copayments and coinsurance were 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 
copayment for specialist visits to diagnose and treat conditions of the eye.  
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs. 
 
Drug/Date Allowed Amount 20% Coinsurance 
Bevacizumab  January 12, 2021 $75.16 $15.03 
Bevacizumab  February 23, 2021 $75.16 $15.03 
Bevacizumab  April 6, 2021 $72.51 $14.50 
Bevacizumab  May 18, 2021 $72.51 $14.50 
Bevacizumab  June 29, 2021 $72.51 $14.50 
Bevacizumab  August 10, 2021 $70.60 $14.12 
Bevacizumab  September 7, 2021 $70.60 $14.12 
Bevacizumab  September 21, 2021 $70.60 $14.12 
Bevacizumab  October 5, 2021 $70.41 $14.08 
Bevacizumab  November 2, 2021 $70.41 $14.08 
Bevacizumab  November 30, 2021 $70.41 $14.08 
Bevacizumab  December 14, 2021 $70.41 $14.08 
Total:  $172.24 
 
The file shows that the Plan has reprocessed the claims and have covered the diagnostic tests. You have been 
asked to pay a $20 copayment for each of the 12 eye exams provided from January 12, 2021, to December 14, 
2021, for a total of $240. The eye exams fall within the Vision Care benefit category. You have also been asked 
to pay $172.24 for the injections, which is 20% of the allowed amount. The injections fall within the Medicare 
Part B Prescription Drugs benefit category. The total for all visits is $412.24. However, the Plan has indicated 
that your cost share amount is only $406.32. 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 copayments and 
coinsurance for eye exams and bevacizumab injections provided from January 12, 2021, to December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for Practitioner Services provided on 
November 10, 2021. 
 
You asked the Plan to waive the deductible for Practitioner Services. You say that you would like to appeal the 
amount of your deductible. The Plan denied your request. The Plan says the member is responsible for 50% 
coinsurance for services rendered after their deductible is met. 
 
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 there is a 50% 
coinsurance and a $1,000 deductible for Practitioner Services. At the time this claim was processed, $226.36 of 
the $1,000 deductible had been met. Your share of the services provided on November 10, 2021 is $289.84 
because the $1,000 deductible had not been met. 
 
You have been asked to pay a $1,000 deductible for Practitioner Services. Practitioner Services falls within the 
Physician/Practitioner Services, including Doctors 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 deductible for Practitioner Services provided on November 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 8, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab services. You say that these services were requested by the enrollee's 
physician. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because this provider is out-of-network with the Plan and the ordering physician was also out-of-network with 
the Plan. 
 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 lab services provided on December 8, 2021 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 shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that your mother does not have much strength and 
shower chair is needed for members safety. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for emergency room (ER) visits provided 
from September 11, 2021, to December 12, 2021. 
 
You asked the Plan to waive the copayments for the ER visits. You say that you were not seen in the ER, only 
the outpatient clinic for IV infusions. 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 emergency room visit.  
 
You have been asked to pay a $50 copayment for each of the ER visits. The file shows a total of 31 ER visits 
from September 11, 2021, to December 12, 2021, for a total of $1,550 ($50 copayment x 31 visits = $1,550). The ER visits fall 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 copayments 
for emergency room (ER) visits provided from September 11, 2021, to December 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vraylar capsules. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not 
covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug 
benefits. 
 
 
 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vraylar capsules.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on March 3, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that a claim for the same procedure code (97110) 
and the same rendering provider was partially paid on February 17, 2021. The Plan denied your request. The 
Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to the services 
being rendered. The Plan also says that regarding the appellant's statement that the Plan paid for similar 
services rendered on February 17, 2021, they reviewed their records and determined that services were not paid 
by the Plan. 
 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 therapeutic exercises (97110) provided on March 
3, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided from 
March 8, 2021, to March 14, 2021. 
 
You asked the Plan to waive the coinsurance for the inpatient hospital care. You say that you would like the 
Plan to work out the charges with the provider. 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 30% 
coinsurance for inpatient care at an out-of-network (OON) facility.  
 
You have been asked to pay $6,089.40, which is 30% of the allowed amount for the OON inpatient hospital 
care ($20,298.00 charged x 30% coinsurance = $6,089.40). The OON inpatient hospital 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 coinsurance for inpatient 
hospital care provided from March 8, 2021, to March 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an ultrasound study of the arteries and a 
nerve function test provided on October 26, 2021. 
 
You asked the Plan to waive the copayments for the ultrasound and nerve function test. You say that your 
policy says it is not your responsibility. 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 $125 
copayment for radiological diagnostic services, not including X-rays. Your contract with the Plan also clearly says that you must pay a $30 copayment for non-radiological 
diagnostic services. 
 
You have been asked to pay a $125 copayment for the ultrasound and a $30 copayment for the nerve function 
test. The total for the visit is $155. The ultrasound and nerve function test fall 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 copayments 
for an ultrasound study of the arteries and a nerve function test provided on October 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the requested services. You say that you will be traveling and need it for the 
long drive. The Plan denied your request. The Plan says there is no evidence that your equipment is not serving 
your needs within the home. 
 
 The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
We looked at the file and the rules. The records show that you currently have a home oxygen system and 
portable oxygen tanks. The requested items serve the same purpose as the items you already have. Based on 
this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by a 
network facility. 
 
 
 
 You asked the Plan to pre-approve the SNF care. You say that you have complex migraine symptoms which 
mimicked a stroke and left side weakness and need physical therapy in an acute rehabilitation facility. The Plan 
denied your request. The Plan says authorization denied because SNF care is not medically necessary and your 
needs can be met at a lower level of care such as home with home health, in residential care, or home with 
close follow-up with your doctor. 
 
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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found Based on the documentation provided, 
you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have 
documented skilled therapy needs. You appear to be functioning at/near her baseline.  Daily skilled services are 
not shown to be required to establish a maintenance program or to prevent deterioration of your condition. 
Your care needs, custodial and intermittent, as a practical matter, can be provided at a lower level of care (ex. 
home, AL, LTC). 
 
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 pre-approve skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you can receive 
the care you need in another setting. 
 
  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not required. Our physician reviewer found that there is no documentation that you 
require services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home 
health care or in a long-term care facility on a part time basis are appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose supplies purchased from November 16, 
2021, to December 16, 2021. 
 
You asked the Plan to pay for these supplies. You say that these supplies were medically necessary. The Plan 
denied your request. The Plan says you did not meet all of the required criteria for these supplies, and you did 
not have prior authorization. 
 
The Plan must follow Medicare rules. Medicare rules say all of the required criteria must be met for coverage 
of this equipment and supplies.  The documentation does not show that at the time of purchase you met all the required criteria. In addition, you 
did not have prior authorization for this purchase. Therefore, we decided that the Plan does not have to pay for 
continuous glucose supplies purchased from November 16, 2021, to December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech/hearing therapy (92507) provided on April 13, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for speech/hearing therapy. You say that another claim for a different date of 
service, February 5, 2021, for the same procedure (92507) was partially paid. The Plan denied your request. 
The Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to the 
services being rendered on April 13, 2021. The Plan also says that regarding the appellant's statement that the 
Plan paid for similar services rendered on February 5, 2021, they reviewed their records and determined that 
was due to an administrative error.  
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 speech/hearing therapy (92507) provided on April 
13, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on June 14, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that another claim for a different date of service, 
February 18, 2021, for the same procedure was partially paid. The Plan denied your request. The Plan says this 
provider is out-of-network with the Plan, and authorization was not obtained prior to the services being 
rendered. The Plan also says that regarding the appellant's statement that the Plan paid for similar services 
rendered on February 18, 2021, they reviewed their records and determined that was due to an administrative 
error. 
 
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 therapeutic exercises (97110) provided on June 
14, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 a Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the requested 
Vertiflex device is experimental. It is not medically reasonable or necessary for the enrollee in this case at this 
time. 
 
 
 
 
 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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.