Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for psychotherapy services provided from 
January 21, 2022, to February 17, 2022. 
 
You asked the Plan to waive the coinsurance for the psychotherapy services. You say that there are no in-
network providers near you. 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 40% 
coinsurance for therapy services with an out-of-network (OON) provider. 
 
 
 
 Service Allowed Amount 40% Coinsurance 
Office Visit  January 21, 2022 $86.17 $34.47 
Psychotherapy  January 21, 2022 $68.42 $27.37 
Office Visit  February 17, 2022 $63.86 $25.54 
Psychotherapy  February 17, 2022 $61.50 $24.60 
Total:  $111.98 
 
The file shows that the Plan verified the provider is out-of-network, and had found two other providers that 
were in-network. Therefore, you have been asked to pay $111.98, which is 40% of the allowed amount for the 
psychotherapy services. The psychotherapy 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. Therefore, we 
decided that the Plan does not have to waive the coinsurance for psychotherapy services provided from January 
21, 2022, to February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for VEMP testing provided on July 27, 2021. 
 
You asked the Plan to pay for VEMP testing. The Plan denied your request. The Plan says the VEMP test is 
experimental/investigational. 
 
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 pay for VEMP testing. Our reviewer says that 
VEMP testing is not considered medically reasonable and necessary. Our physician reviewer found that the 
record indicates that the enrollee has Meniere's disease with sensorineural hearing loss. There is insufficient 
literature to support the safety and efficacy, as defined by Medicare rules, of the requested test for the requested service. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VEMP testing have not been met. Therefore, we decided that the Plan does not 
have to pay for VEMP testing provided on July 27, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you have 
no daily skilled nursing or therapy needs. 
 
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 continued services. Our physician 
reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, 
uncomplicated wound care, and your lungs were clear. There are no identifiable skilled nursing service needs. 
Regarding rehabilitation services, you were at a supervision assist to maximal assist level for functional 
mobility. You required varying assist with activities of daily living. There are no identifiable skilled therapy 
service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity 
of illness or intensity of service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have COPD and HFrEF, with a 
recent hospitalization for acute on chronic respiratory failure. This appears to be a combination of COPD 
exacerbation and heart failure exacerbation. You likely have chronic hypercapnic respiratory failure, although 
there is no ABG done as an outpatient, while stable, to document this. You may benefit from bipap during 
sleep as an outpatient, with or without the AVAPS mode, but this has not been tried.  Medicare does not pay for a home ventilator when used as bipap. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
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 care. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee received oral medications and IV 
antibiotics for 22 days. The enrollee had stable vital signs and had foley catheter care. He was at a maximal 
assist level for functional mobility. The enrollee does require skilled nursing or therapy services on a daily 
basis. He does meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing 
facility setting. 
 
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 care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
January 4, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that the provider informed you that 
there were no copayments. 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 $25 
copayment for each physical therapy visit.  
 You have been asked to pay a $25 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 copayment for physical 
therapy (PT) services provided on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear provided on October 12, 2021. 
 
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says the claim processed 
according to the member's Plan benefit. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services when purchased from a network optical provider. 
 
 We looked at the file and the Plan's rules. The file shows that the eyewear was not purchased from a network 
optical provider. Based on this information, we decided that the Plan's rules for coverage of the eyewear have 
not been met. Therefore, we decided that the Plan does not have to pay for eyewear provided on  
October 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron 
 
You asked the Plan to pre-approve Ondansetron. You say that the requested drug is needed for nausea and 
vomiting. The Plan denied your request. The Plan says the requested drug is not covered under Part B and is 
covered under a pharmacy benefit. The Plan says that the enrollee has no pharmacy benefit under this contract. 
 
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 Ondansetron  
 Benefits for Ondansetron 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the barium swallow study provided by a mobile radiology 
provider on December 21, 2021. 
 
You asked the Plan to pay for the barium swallow study provided by a mobile radiology provider. You say that 
this is medically necessary and should be covered. The Plan denied your request. The Plan says this is excluded 
from Medicare coverage.  
The Plan must follow Medicare rules. Medicare rules say that portable/mobile radiology services are covered 
only for certain types of imaging. Imaging that involves contrast media are noncovered in this setting. 
 
We looked at the file and Medicare rules. The services at issue involve contrast media and were provided in a 
portable radiology setting. Based on this information, we decided that Medicare rules for coverage of the 
barium swallow study provided by a mobile radiology provider have not been met. Therefore, we decided that 
the Plan does not have to pay for the barium swallow study provided by a mobile radiology provider on 
December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for physician's services provided on  
December 13, 2021, and January 20, 2022. 
 
You asked the Plan to waive the deductible for the physician's services. You say that when you signed up for 
this Plan you were told everything would be covered. The Plan denied your request. The Plan says the claims 
processed appropriately according to the billing by the provider for services rendered and the structure of your 
Medicare benefit plan. The Plan says this deductible amount must be paid out-of-pocket before we pay our 
share for your covered medical services. 
 
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 $233.00 deductible which applies to covered medical services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category of Plan 
deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $233.00 
deductible which applies to covered medical services. This cost sharing is a contractual obligation that had not 
been met at the time the physician's services were received on December 13, 2021, and January 20, 2022. Therefore, we decided that the Plan does not have to waive the deductible for physician's services provided on 
December 13, 2021, and January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 24, 
2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that the facility was urgent care, 
not a hospital. 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 $65 
copayment for urgently needed services.  
 
You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently Needed 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 copayment for an urgent 
care visit provided on January 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for inpatient rehabilitation care 
provided from October 23, 2020, to November 4, 2020. 
 
You asked the Plan to waive or reduce the copayment for the inpatient rehabilitation care. You say that you are 
on social security and cannot afford the bill. 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 $300 per 
day for days 1-5 and $0 per day for additional days for each inpatient admission.  
 
The file shows that you were in the rehabilitation facility from October 23, 2020, to November 4, 2020. Therefore, you have been asked to pay $300 per day for the first 5 days of inpatient rehabilitation care. The 
total for your stay is $1,500 ($300 copayment x 5 days = $1,500). The inpatient rehabilitation 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 or reduce the copayment for 
inpatient rehabilitation care provided from October 23, 2020, to November 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home portable ventilator (E0466). 
 
You asked the Plan to pre-approve a home portable ventilator. You say that the enrollee is high risk for 
readmission and for a ventilator use in ICU. You also say the enrollee has tried a bipap and failed during 
hospital stay. She is delicate and needs a noninvasive ventilator. The Plan denied your request. The Plan says 
The requested device would be used in a BiPAP mode that could be provided with a BiPAP (E0471) device 
with AVAPS added to assure adequate tidal volumes. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 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 home portable ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has COPD 
with a recent hospitalization for acute on chronic hypercarbic respiratory failure.  The enrollee may benefit 
from bipap support during sleep.  But bipap, with or without AVAPS, has not been tried as an outpatient. There 
is no ABG as an outpatient, while stable, confirming chronic CdO2 retention.  Medicare does not pay for a 
ventilator when used as bipap. 
 
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 home portable ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home portable ventilator (E0466).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you received oral medications, had stable vital 
signs and used oxygen via nasal cannula. You were at a contact guard to minimal assist level for functional 
mobility including gait to 50 feet with a rolling walker. You do not require skilled nursing or therapy services 
on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility setting. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel One knee injections. 
 
You asked the Plan to pre-approve the Gel One injections. You say that you feel that this should be approved. 
The Plan denied your request. The Plan says you are required to try preferred alternative drugs before a non-
preferred drug can be approved. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel One injections. Our reviewer 
says that the requested drug is not considered medically necessary based on step therapy rules. Our physician 
reviewer found based on the medical records provided, there is no indication that the patient has tried and failed 
the required drugs, Orthovisc or Synvisc. There is no indication that the plan's required drug(s) would likely be 
less effective and/or likely have adverse effects for the patient. 
 
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 Gel One injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Gel One knee injections.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that the requested medication is medically necessary. The 
Plan denied your request. The Plan says the requested medication does not meet criteria. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
 
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 Aranesp. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is noted to have anemia in the setting of chronic kidney disease. A request has been 
made for Aranesp to treat the anemia. The health plan requires that other forms of anemia medications be used.  
There is no evidence that the enrollee is allergic to or intolerant of these other forms of medication. There is no 
evidence that the enrollee has tried and not responded to these other forms of medication. There is no 
documentation as to why these other forms of medication would not be expected to be safe and effective for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).