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

 
We decided that the Plan does not have to pay for outpatient hospital services provided on November 30, 2021. 
 
You asked the Plan to pay for outpatient hospital services. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 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hospice election has been revoked or terminated.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 2, 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 outpatient hospital 
services provided on November 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alosetron 1mg tablets. 
 
You asked the Plan to pre-approve Alosetron. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
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 Alosetron 1mg tablets.  
 
Benefits for Alosetron may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the binaural, in the ear hearing aids (V5130) provided 
November 2, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you were not aware that the provider was OON. 
The Plan denied your request. The Plan says the hearing aids are not covered because they were provided 
OON. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from a network provider.   
We looked at the file and the Plan's rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the binaural, 
in the ear hearing aids (V5130) provided November 2, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis services (20610) provided on 
November 1, 2021. 
 
You asked the Plan to waive the copayment for the arthrocentesis services. You say that the services should be 
covered. 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 $295 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
 
  You have been asked to pay a $233.98 copayment for the arthrocentesis services, which is less than the 
standard $295. Arthrocentesis falls within the Outpatient Surgery and Other Medical Services Provided at 
Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for arthrocentesis services (20610) provided on November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory services provided on September 
1, 2021. 
 
You asked the Plan to waive the deductible for the laboratory services. You say that your lab services 
copayment should be $0. The Plan denied your request. The Plan says the correct amount was applied to your 
deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $198 deductible which applies to certain items and services.  
 
The laboratory services you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $198 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the laboratory services was received on 
September 1, 2021. Therefore, we decided that the Plan does not have to waive the deductible for laboratory 
services provided on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the resin-based composite - two 
surfaces, posterior (D2392) provided July 7, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to provide additional payment for the filling. You say that you were unable to find an in-
network provider and the OON provider said the services would be covered. The Plan denied your request. The 
Plan says this service was correctly processed according to your OON benefits. 
 
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. The Plan covers the filling 
with 55% coinsurance when provided OON.  
 We looked at the file and Medicare rules. In this case you have been asked to pay 55% of the allowed amount 
for the filling ($111 allowed amount x 55% coinsurance = $61.05). Additionally, the provider may bill you for 
the difference between the Plans allowed amount and the total cost billed by the OON provider. Therefore, we 
decided that the Plan does not have to provide additional payment for the resin-based composite - two surfaces, 
posterior (D2392) provided July 7, 2021, by an out-of-network (OON) provider.  
 
Your complaint about issues finding a network provider is not a valid appeal for medical coverage. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that it is a hassle taking the 
oxygen tank to appointments and you wanted a portable one so you can carry and take it with you. The Plan 
denied your request. The Plan says the provider has not filled out and submitted a certificate of medical 
necessity for you to use a portable oxygen concentrator. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Oxygen is covered when the provider has filled out and submitted a 
certificate of medical necessity. The Plan made multiple attempts to obtain additional information from the 
provider without success.  
 Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the portable oxygen 
concentrator (E1392).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services received from 
September 15, 2021, to September 16, 2021. 
 You asked the Plan to waive the copayment for the services. You say that this should be paid for. The Plan 
denied your request. The Plan says the copayments were applied 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay various copayments for the services received on the first claim. 
 
You have been asked 20% coinsurance for the Part B drugs, $37.84 and $22.31. These services fall within the 
Medicare Part B prescription drugs benefit category. 
 
You have been asked to $75.21 for the diagnostic chest x-ray received. The copayment is usually $90, but the 
allowed amount for the service was less than that. This service falls within the basic radiology benefit category. 
 
You have been asked to pay a $174.79 copayment for the computed tomography (CT) scan. There is normally 
a $295 copayment, but the allowed amount was less. This service falls within the advanced imaging benefit 
category. 
 
You have been asked to pay a $40 copayment for physical therapy services. This service falls within the 
outpatient hospital physical therapy benefit category. 
 
You have been asked to pay a $50 copayment for echocardiography. This service normally has a $90 
copayment, but the allowed amount was less than this. This service falls within the basic radiology benefit 
category. 
 
You have been asked to pay a $160 copayment for the magnetic resonance imaging (MRI). This service 
normally has a $295 copayment, but the allowed amount was less than this. This service falls within the 
advanced imaging services benefit category. 
 
The second claim was corrected, and there is no member responsibility for this one. 
 
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 outpatient services received from September 15, 2021, to 
September 16, 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 this service is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has 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 is not shown to require fifteen hours per week of rehabilitative services 
and regular physician evaluation. The enrollees care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (62322). 
 
You asked the Plan to pre-approve the epidural steroid injections. You say that this service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that  injections performed without image guidance or by 
ultrasound are not considered medically reasonable and necessary except in cases of documented 
contraindication to contrast media (e.g., allergy, pregnancy).  
 
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 epidural steroid injections. Our 
reviewer says that the injections are not medically necessary. Our physician reviewer found there is no 
documentation that the enrollee's pain is severe enough to greatly impact the quality of life or function as 
measured on a pain and/or functional assessment scale. In addition, there is no documentation indicating that 
the requested epidural steroid injection will be performed with image guidance. 
 
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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections (62322).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on November 10, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on  
November 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve the skilled nursing facility. You say that the skilled nursing facility services 
are medically necessary. The Plan denied your request. The Plan says coverage criteria 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 the skilled nursing facility. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does 
not require skilled nursing or therapy services on a daily basis. 
 
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 skilled nursing facility have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PureWick catheter and supplies (CPT code K1006). 
 
You asked the Plan to pre-approve the PureWick catheter and supplies. You say that you have been using this 
item since April 2021, and you have become dependent on it for your condition. The Plan denied your request. 
The Plan says you previously purchased PureWick catheter system out of pocket; however, Medicare does not 
cover the PureWick female catheter or its related components. The Plan states PureWick is not covered by 
Original Medicare due to the lack of scientific evidence of benefit. The Plan states there are other items that 
can be used for incontinence, such as pads/diapers, bed pans, or indwelling catheters (a tube inserted into the 
bladder to assist with urinating) in the home. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
 
 PureWick is not covered by Original Medicare due to the lack of scientific evidence of benefit. The Plan states 
there are other items that can be used for incontinence, such as pads/diapers, bed pans, or indwelling catheters 
(a tube inserted into the bladder to assist with urinating) in the home. Therefore, we decided that the Plan does 
not have to pre-approve the PureWick catheter and supplies (CPT code K1006).
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 the services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has 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 is not shown to require fifteen hours per week of rehabilitative services 
and regular physician evaluation. The enrollees care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ambulance services provided on 
September 1, 2021. 
 
You asked the Plan to waive the coinsurance for the ambulance services. You would like the Plan to make an 
exception to process at the in-network level. The Plan denied your request. The Plan says the cost sharing 
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 40% 
coinsurance for each one-way Medicare covered trip from an out-of-network provider.  
 
 Date of Service Service Provided Allowed 
Amount 
Cost-Share per 
Contract 
Your Cost-Share 
Responsibility 
September 1, 2021 Advanced life 
support; emergency 
transport 
$432.28 40% coinsurance $172.87 
September 1, 2021 Ground mileage $38.15 40% coinsurance $15.26 
Total:    $188.13 
 
You have been asked to pay $188.13 for the ambulance services. The in-network copayment for each one-way 
Medicare covered trip from an in-network provider is $300. You are being asked to pay less than the in-
network amount. The ambulance services fall 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 coinsurance for the ambulance services provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and diagnostic testing to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visit and diagnostic tests. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network 
thoracic surgery specialist. 
 
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 
an office visit and diagnostic testing to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency care services provided on July 27, 2021. 
 
You asked the Plan to pay for emergency care services. You say that the emergency care services should be 
covered by the Plan. The Plan denied your request. The Plan says that the services were provided out-of-
network and were not approved in advance. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for emergency care 
services provided on July 27, 2021.  
 
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.