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

 
We decided that the Plan does not have to waive the copayment for Skilled Nursing Facility (SNF) on 
December 24, 2020, to January 21, 2021 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF). You say that you want to appeal 
the amount. The Plan denied your request. The Plan says Days 1-20: $0 copayment per day, per admission; 
Days 21-100: $100 copayment per day, per admission. A benefit period starts the day you go into a hospital 
or skilled nursing facility. It ends when you go 60 days in a row without hospital or skilled nursing care. If you 
go into the hospital or SNF after one benefit period has ended, a new benefit period begins. There is no limit to 
the number of benefit periods you can have.  
 
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 $100 copayment for days 23-29 of skilled nursing facility care. There were 29 total days, resulting 
in a total copayment amount of $900.   
 
 
 The enrollee has been asked to pay a $100 copayment for skilled nursing facility (SNF). Skilled nursing facility 
(SNF) falls within the Skilled nursing facility care benefit category. The enrollee has a $100 copayment for 
days 23-29. The provider billed the plan $14,079.56. The plan approved amount was $10,137.22 and the plan 
paid $9,237.22. The enrollee is responsible for a $900 copayment. 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) on December 24, 2020, to January 21, 2021
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF care is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare SNF coverage criteria. 
 
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 
SNF services are not medically necessary. Our physician reviewer found that based on the documentation 
provided, the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more 
than 100 feet. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs are custodial and can, as a practical matter, 
be provided at a lower level of care (ex. home, assisted living, long term 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 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 pre-approve a walk-in tub. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in tub.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray and office visit provided by a 
specialist on October 4, 2021. 
 
You asked the Plan to waive the copayment for services provided by a specialist on October 4, 2021. You say 
that you were not aware of the copayment responsibility. The Plan denied your request. The Plan says enrollees 
must pay a $50 copayment for items and services provided by a specialist. 
 
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 Physician/Practitioner Services, Including Doctor's Office Visits.  
 
You have been asked to pay a $50 copayment for the x-ray and office visit on October 4, 2021. The x-ray and 
office visit on October 4, 2021 fall 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 the x-ray and office visit 
provided by a specialist on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested provider. You say that 
you have used this provider before. You say the new patient appointment to the in-network provider has a 2-
week lead time for patient appointments. The Plan denied your request. The Plan says the member must use 
network providers to get medical care and services. Page 45 of the EOC documents circumstances in which the 
plan allows members to see out-of-network providers. The requested services are not urgent/emergent, plan 
providers are available to perform the services, and the request is not for out-of-area dialysis. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the 
requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stationary exercise bike. 
 
You asked the Plan to pre-approve a stationary exercise bike. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a stationary exercise bike.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery back-up power source. 
 
You asked the Plan to pre-approve a battery back-up power source. You say that you need this due to power 
outages. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a battery back-up power source.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services performed on  
February 12, 2022. 
 
You asked the Plan to waive the copayment for laboratory services performed on February 12, 2022. You say 
that the plan did not pay for the allowed cost of the laboratory service. The Plan denied your request. The Plan 
says enrollees must pay a $10 copayment for Medicare-covered laboratory services. 
 
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 $10 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $9.71 copayment for laboratory services. Laboratory services fall within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. For this service, the 
provider billed $152; the Plans allowance was $9.71. Since the Plans allowance was less than the required 
$10 copayment, you have only been asked to pay the lower amount. 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 laboratory services performed on 
February 12, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the $40 copayment for a Specialist physician visit on July 19, 2021. 
 
You asked the Plan to waive the $40 copayment for a Primary Care physician visit on July 19, 2021. You say 
that you should not be responsible for a copayment. The Plan denied your request. The Plan says that there is a 
$40 copayment for each Specialist visit. 
 
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 enrollees must pay a $0 copayment for each Primary Care Physician visit.  
 
The Plan says you must pay a $40 copayment for each Medicare-covered Specialist visit. Based on the Plan 
contract, however, you cannot be asked to pay more than $0 copayment for a Primary Care Physician visit. Of 
note, the records support that you received services from the office of your primary care physician. It is not 
appropriate for the Plan to apply the specialist copayment in this case. Therefore, we decided that the Plan has 
to waive the $40 copayment for a Primary Care physician visit on July 19, 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.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient mental health services rendered 
July 21, 2021, to October 13, 2021.  
 
You asked the Plan to waive the copayments for outpatient mental health services rendered July 21, 2021, to 
October 13, 2021. You say that these services were not rendered because you had cancelled all your 
appointments. The Plan denied your request. The Plan says you must pay a $40 copayment for each Medicare-
covered individual session provided by a mental health professional other than a psychiatrist. 
 
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 $40 
copayment for Outpatient Mental Health Care.  
 You have been asked to pay a $40 copayment for outpatient mental health services. Outpatient mental health 
services fall within the Outpatient Mental Health 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. In your appeal, you said you did not receive these services. 
Records submitted support these charges. Therefore, we decided that the Plan does not have to waive the 
copayments for outpatient mental health services rendered July 21, 2021, to October 13, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prism glasses. 
 
You asked the Plan to pre-approve prism glasses. You say that you need prism glasses due to having vision loss 
due to a stroke. The Plan denied your request. The Plan says prism glasses are not covered by Medicare or by 
the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear. 
 
We looked at the file the Medicare rules and the Plan's rules. The file shows that Medicare and the Plan do not 
cover prism glasses. Therefore, we decided that the Plan does not have to pre-approve prism glasses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller 
upgrade, harness upgrade, and electronic connection between wheelchair controller and two or more power 
seating system motors. 
 
You asked the Plan to pre-approve a power seat elevation system, expandable controller upgrade, harness 
upgrade, and electronic connection between wheelchair controller and two or more power seating system 
motors. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan 
says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications.  
 
We looked at the file and Medicare rules. The requested power seat elevation feature is strictly non-covered. 
Although there are three requested power options, there is no documentation of a medical need to control these 
options through the joystick. The enrollee is self-driving and is independent with feeding, bathing, grooming, 
upper body dressing, and toileting. The enrollees upper limb strength and function are adequate to be able to 
control the power options using their own switches which are included in the allowance of the approved power 
options. Based on this information, we decided that Medicare rules for coverage of a power seat elevation 
system, expandable controller upgrade, harness upgrade, and electronic connection between wheelchair 
controller and two or more power seating system motors have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power seat elevation system, expandable controller upgrade, harness 
upgrade, and electronic connection between wheelchair controller and two or more power seating system 
motors.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network physical therapist. 
 
You asked the Plan to pre-approve these services. You say that regular physical therapy does not work for you. 
The Plan denied your request. The Plan says the services are available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network physical therapist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a backup battery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve primary care provider (PCP)services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the PCP services. You say that you are a cancer patient and you have been 
seeing this doctor and is familiar with your condition. The Plan denied your request. The Plan says the provider 
is out-of-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 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 PCP services. We found no exception that would require the Plan to pre-approve 
the PCP services. Therefore, we decided that the Plan does not have to pre-approve primary care provider 
(PCP)services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. You say that the member 
does not have any transportation for his dialysis appointments, which are three time a week and his wife does 
not drive and they do not have any help. The Plan denied your request. The Plan says the beneficiary exhausted 
the established benefit of 24 one-way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation trips. 
 
You asked the Plan to pre-approve additional transportation trips. You say that you are unable to see out of one 
of your eyes due to a recent surgery and you need help getting around. You say that you need additional 
transportation. The Plan denied your request. The Plan says only 20 one-way trips are allowed per year and 
extra trips cannot be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the Medicare criteria 
for LTACH. The Plan denied your request. The Plan says authorization denied because the LTACH is 
medically necessary, and the enrollee's needs can continue to be met at the current acute hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to still be unstable and requires additional acute care services 
that can safely be completed at the current facility until more stable for transfer. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility.  
 
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 LTACH services have not been met. 
  
Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) 
services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lymphedema pump and related leg and trunk sleeves 
for use in the home to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the lymphedema pump and related leg and trunk sleeves for use in the 
home. You say that you need this equipment, and you do not know why the Plan would deny it. The Plan 
denied your request. The Plan says the provider is out-of-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 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 lymphedema pump and related leg and trunk sleeves for use in the home. We 
found no exception that would require the Plan to pre-approve the lymphedema pump and related leg and trunk 
sleeves for use in the home. Therefore, we decided that the Plan does not have to pre-approve the lymphedema 
pump and related leg and trunk sleeves for use in the home to be provided by an out-of-network (OON) 
provider.