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

 
We decided that the Plan does not have to waive the deductible for an inpatient hospital stay provided from 
August 24, 2021, to August 29, 2021. 
 
You asked the Plan to waive the deductible for the inpatient hospital stay. You say that the services should be 
covered as you disagree with the charges. 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. Your 
contract with the Plan says that there is a $1000 deductible which applies to Inpatient hospital care.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Inpatient 
hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 
deductible which applies to Inpatient hospital care. This cost sharing is a contractual obligation that had not 
been met at the time the inpatient hospital stay was received on August 24, 2021, to August 29, 2021. 
Therefore, we decided that the Plan does not have to waive the deductible for an inpatient hospital stay 
provided from August 24, 2021, to August 29, 2021.  
 
Since the $1,000 deductible was met, you have also been asked to pay a 30% coinsurance (allowed is 
$16,935.75 x 30% = $5,080.72) for a total cost-sharing of $6,008.23. 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Levalbuterol Tartrate HFA (J3535). 
 
You asked the Plan to pre-approve Levalbuterol Tartrate HFA. You say that this drug is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the 
Plan's 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 Levalbuterol Tartrate HFA 
(J3535).  
 Benefits for Levalbuterol Tartrate HFA 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Telehealth services on January 7, 2022 to 
January 14, 2022. 
 
You asked the Plan to waive the coinsurance for Telehealth services. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says the 20% coinsurance you are being charged 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 a 20% 
coinsurance for Telehealth services. The allowed amount of this Telehealth services is $299.80, resulting in a 
coinsurance amount of $59.96. 
 
You have been asked to pay a 20% coinsurance for Telehealth services. Telehealth services falls within the 
Physician/Practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for Telehealth services on January 7, 2022 to January 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for cataract surgery provided on January 10, 
2022. 
 
You asked the Plan to reduce the cost share for cataract surgery. You say that you were supposed to have your 
second eye surgery before the end of December, but the office had to reschedule the appointment. You also say 
that you thought your cost share would have been 20% like your first surgery. 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 $390 
copayment for outpatient surgery.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$390 copayment for cataract surgery. Cataract surgery falls within the Outpatient Surgery, Including 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 reduce the cost share for cataract surgery provided on January 10, 2022.
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 services. You say that the SNF 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 services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found daily skilled services 
are not required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs, as a practical matter, can be provided 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 the skilled nursing facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility services.
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 does not meet 
criteria. 
 
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 you are medically stable and do not need PM&R physician close supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. While you may benefit from physical therapy, and occupational therapy, your rehab can be safely 
provided at a lower intensity and alternate setting such as in a skilled nursing facility or in-home with services. 
 
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 pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional trips 
for dialysis. The Plan denied your request. The Plan says additional trips would exceed your benefit limit. 
 
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 60 trips per year.  
 
 
 We looked at your request, the records in the case file, and the rules. The records show that you have used 
fifty-seven (57) one-way transportation trips out of the allowed sixty (60) one-way trips approved. Once 60 
trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional routine transportation trips (A0120).
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 does not meet 
criteria. 
 
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 medically stable and does not need PM&R physician close supervision 
3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. While the enrollee may benefit from physical therapy, and occupational therapy, the 
enrollee's rehab can be safely provided at a lower intensity and alternate setting such as in a skilled nursing 
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 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 copayments for a specialist office visit and laboratory 
services provided on December 2, 2021. 
 
You asked the Plan to waive the copayments for the specialist visit and lab services. You say that you did not 
have blood work done. You say that this was your regular screening and should not have a copayment. 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 $30 
copayment for each specialist office visit. Your contract with the Plan also clearly says that you must pay a $10 copayment for lab services.  
 
You have been asked to pay a $30 copayment for the specialist visit. The specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to 
pay $4.23 for the lab services, which is less than the $10 copayment. The lab services fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. The total for your visit is $34.23. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for a specialist office visit and laboratory services provided on 
December 2, 2021.
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 the enrollee received oral medications and had 
stable vital signs. The enrollee was at a contact guard/minimal assist level for functional mobility including gait 
to 100 feet. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (82728, 83540, 83550, 83970) provided 
on October 5, 2021. 
 
You asked the Plan to pay for laboratory services. You say that there is no contractual agreement in place to 
include these services in the dialysis rate. The Plan denied your request. The Plan says these services cannot be 
paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of end-stage renal disease (ESRD) are included in the ESRD Prospective Payment System 
(PPS) as Part B services and are not paid separately. 
 
We looked at the file and Medicare rules. The laboratory services at issue were provided for the treatment of 
ESRD. Based on this information, we decided that Medicare rules for coverage of laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for laboratory services (82728, 83540, 
83550, 83970) provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you would like to get treated outside 
of the Plans providers because they have not diagnosed you properly. The Plan denied your request. The Plan 
says there are 45 rheumatologists within the enrollee's region that are in-network who can properly treat the 
enrollee. Therefore, the referral to an out-of-network provider in not approved. 
 
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 specialist office visit to be provided by an out-of-network (OON) provider.
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 services. You say that the SNF 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 services. 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. The enrollee's 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 the skilled nursing facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit provided on 
December 15, 2021. 
 
You asked the Plan to waive the copayment for an outpatient office visit. You say that you think the copayment 
should not apply because you did not see the doctor you think you should have. The Plan denied your request. 
The Plan says the claim reprocessed to only apply a $10 copayment.  
 
  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 office visits.  
 
You have been asked to pay a $10 copayment for an outpatient office visit. Outpatient office visit falls within 
the Physician/Practitioner services, including doctor's office visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the outpatient office visit provided on December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 20, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that this patient has been followed by you for stage 
3 kidney disease since February 2021, prior to becoming effective with this Plan, and the patient continues to 
follow-up for continuity of care. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan, we have also determined that these services are not urgent or emergent, nor were they 
approved in advance. 
 
 
 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 January 20, 2022, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty services. 
 
You asked the Plan to pre-approve kyphoplasty services. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says the requested procedure is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that fracture retropulsion/canal compromise is a contraindication 
to kyphoplasty services. 
 
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 kyphoplasty services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the imaging shows fracture retropulsion into the spinal canal and that is a 
contraindication to kyphoplasty. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve kyphoplasty services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 29, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that there were no in-network doctors available who 
could provide the Tulsa-Pro treatment. The Plan denied your request. The Plan says no prior authorization was 
obtained. 
 
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 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 the office visit provided on March 29, 2021, by an 
out-of-network (OON) provider.