Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient services provided from 
February 4, 2022, to February 15, 2022, and from March 16, 2022, to March 31, 2022. 
 
You asked the Plan to waive the copayments for the inpatient services. You say that these hospital stays were 
part of the same benefit period as the first hospital stay, and you believe the copays should not have been 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $295 copayment per day for days 1 to 5, and a $0 copayment per day for days 6 to 90 for Inpatient 
hospital care.  
 
 
 
 The enrollee has been asked to pay a $295 copayment per day for days 1 to 5, and a $0 copayment per day for 
days 6 to 90 for the inpatient services. These services fall within the Inpatient hospital 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 copayments for the inpatient services provided from February 
4, 2022, to February 15, 2022, and from March 16, 2022, to March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing because the doctor's office 
failed to send in a pre-authorization form for approval. The Plan denied your request. The Plan says the 
enrollee must receive care from a 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 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 laboratory services provided on June 13, 2022, by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from December 1, 
2021, to January 12, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that this should be covered. 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 $0 
copayment for SNF care for days 1 through 20 and then $184 copayment for days 21-100.  
 
You have been asked to pay a total of $2,252 copayment for 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 December 1, 2021, to January 12, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bedside drainage bag (A4357), ostomy skin barrier 
(A4407), and ostomy pouch (A4432) provided from April 28, 2022, to June 21, 2022. 
 
You asked the Plan to pay for the supplies. You say that the services were medically necessary. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the bedside drainage bag (A4357), ostomy skin barrier 
(A4407), and ostomy pouch (A4432) provided from April 28, 2022, to June 21, 2022.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 made good progress in a limited period of time as pain improved and 
with little therapy. He does not require intensive therapy and does not have complex or specialized needs. He 
does not require frequent physiatry oversight. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutritional therapy, initial assessment and 
intervention (97802 x 4), and medical nutritional therapy, re-assess medical nutrition therapy (97803 x 6). 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that this needs to be approved. 
You also say that it is medically necessary. The Plan denied your request. The Plan says there is no evidence 
that you have any of the qualifying conditions for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutritional therapy, initial assessment and intervention (97802 x 4), and 
medical nutritional therapy, re-assess medical nutrition therapy (97803 x 6).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for ophthalmic diagnostic imaging and a 
specialist office visit provided on July 13, 2022. 
 
You asked the Plan to waive the cost sharing for ophthalmic diagnostic imaging and a specialist office visit. 
You say that you are appealing this cost sharing. 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 an $80 
copayment for each covered diagnostic procedure or test at a network doctors office. Your contract with the 
Plan also clearly states that you must pay a $50 copayment for a specialist office visit.  
 
 You have been asked to pay $40.59 for the ophthalmic diagnostic imaging, which is less than the standard $80 
copayment. You have also been asked to pay $50 for a specialist visit. The total amount you owe is $90.59 
($40.59 + $50 = $90.59). The ophthalmic diagnostic imaging falls within the diagnostic procedure or test 
benefit category. The specialist office visit falls within the specialist office visit 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 sharing for ophthalmic diagnostic imaging and a specialist office visit provided 
on July 13, 2022.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a 
day and five days a week, or 15 hours over seven consecutive days. The enrollee has had a functional decline 
from her baseline level of function and will likely benefit from therapy, but she does not require the intensity of 
therapies provided on acute inpatient rehabilitation. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for deductible provided on August 12, 2022. 
 
You asked the Plan to waive the deductible for deductible. You say that you feel the visit should have been 
free. 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. Your 
contract with the Plan says that there is a $192 deductible which applies to Section 1.2 What is your plan 
deductible?  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $192 deductible which 
applies to Section 1.2 What is your plan deductible? This cost sharing is a contractual obligation that had not 
been met at the time deductible was received on August 12, 2022. Therefore, we decided that the Plan does not 
have to waive the deductible for deductible provided on August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on May 31, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chronic care management services. You say that the services were medically 
necessary, and you are appealing with supporting records. The Plan denied your request. The Plan says the 
enrollee must receive care from a 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 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 chronic care management services provided on 
May 31, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for continuous glucose monitor (CGM) 
and supplies (K0553) provided on July 9, 2022. 
 
You asked the Plan to pay for the CGM. You say that the item is not related to the enrollee's hospice diagnosis. 
You also say that this should be covered. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the supply allowance for continuous glucose monitor (CGM) 
and supplies (K0553) provided on July 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 29, 
2022, to July 1, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are requesting 
reconsideration for the cost 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 you must pay $370 
copayment for days 1 to 5 for inpatient hospital care. This inpatient hospital stay lasted 2 days, resulting in a 
copayment amount of $740 ($370 per day for 2 days = $740). 
 
You have been asked to pay $370 copayment for days 1 to 5 for inpatient hospital care. 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 care provided on June 29, 2022, to July 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits and a punch biopsy of skin provided on February 
15, 2022 to May 23, 2022, by an OON provider. 
 
You asked the Plan to pay for the office visits and a punch biopsy of skin. You say that you thought the 
provider was on an approved list. The Plan denied your request. The Plan says the out-of-network services 
were not authorized. 
 
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 office visits and a punch biopsy of skin provided 
on February 15, 2022 to May 23, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) sensors. 
 
You asked the Plan to pre-approve the CGM sensors. You say that the items are medically necessary. The Plan 
denied your request. The Plan says use insulin with at least three daily injections or require frequent self-
adjustment of insulin dosage based on the blood glucose testing results. You have not had an in-person visit 
with your treating physician to assesses adherence to your CGM regimen and diabetes treatment plan 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. You have not had an in-person visit with your treating physician to assesses adherence 
to your CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules 
for coverage of the CGM sensors have not been met. Therefore, we decided that the Plan does not have to pre-
approve the continuous glucose monitor (CGM) sensors.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on August 5, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you needed this medication because 
you were diagnosed with a urinary tract infection. The Plan denied your request. The Plan says this claim was 
processed correctly and in accordance with your 2022 Evidence of Coverage and Medicare guidelines 
 
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 pay for the self-administered drugs 
provided on August 5, 2022.  
 
Benefits for the self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 
22, 2022, to June 24, 2022 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you dont have the money 
to pay the copayment. 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 $295 
copayment for inpatient hospital care.  
 
You have been asked to pay a $295 copayment for inpatient hospital care. 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 care provided from June 22, 2022, to June 24, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 6, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the enrollee must receive care from a 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 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 laboratory services provided on September 6, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a foot, arch support provided on July 9, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the foot, arch support. You say that these services are medically necessary. The 
Plan denied your request. The Plan says the out-of-network services were not authorized and these services can 
be provided 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 a foot, arch support provided on July 9, 2022, by 
an OON provider.